ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
HESI Exit RN Exam Over 700 Questions, Answers Rationale New 2019/2020 latest 100%. 1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? Review with the client the need to avoid foods that are rich in milk and cream 2. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him ―feel bad‖. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? Stroke secondary to hemorrhage 3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. 4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up? Describes life without purpose 5. A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client’s teaching plan? Further evaluation involving surgery may be needed 6. A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? Teach tracheal suctioning techniques 7. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths / minute. What action should the nurse implement? Document the assessment data Rational: reservoir bag should not deflate completely during inspiration and the client’s respiratory rate is within normal limits. 8. During shift report, the central electrocardiogram (EKG) monitoring system alarms.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) Which client alarm should the nurse investigate firs? Respiratory apnea of 30 seconds 9. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first? Check the client for lacerations or fractures 10. At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? Inform the anesthesia care provider 11. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first? Listen with the bell at the same location 12. A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs? Medicare 13. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? Toasted wheat bread and jelly 14. Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? “I have a headache that gets worse when I sit up”
―I am having pain in my lower back when I move my legs‖
―My throat hurts when I swallow‖
“I feel sick to my stomach and am going to throw up”
15. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? Obtain a clean catch mid-stream specimen 16. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child’s dietary restrictions. Which foods are contraindicated for this child? Foods sweetened with aspartame 17. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide? Direct the nurse to continue the surgical hand scrub for a 5 minute duration 18. Which breakfast selection indicates that the client understands the nurse’s instructions about the dietary management of osteoporosis?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Bagel with jelly and skim milk
19. The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied
20. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child’s foot. Which action should the nurse implement first? Cleanse the foot with soap and water and apply an antibiotic ointment Provide teaching about the need for a tetanus booster within the next 72 hours. have the mother check the child's temperature q4h for the next 24 hours transfer the child to the emergency department to receive a gamma globulin injection 21. The mother of an adolescent tells the clinic nurse, ―My son has athlete’s foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement.‖ What instruction should the nurse provide? Stop using the ointment and encourage complete drying of the feet and wearing clean socks. 22. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences Bradycardia and constipation Lethargy and lack of appetite Muscle cramping and dry, flushed skin Palpitations and shortness of breath 23. A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? Obtain a list of medications taken for cardiac history 24. The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.) 75 Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour 25. The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) Fluid shifts from intravascular to interstitial area due to decreased serum protein Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) Increased circulating aldosterone levels that increase sodium and water retention 26. The nurse is auscultating a client’s heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies) Murmur Rationale: A murmur is auscultated as a swishing sound that is associated with the blood turbulence created by the heart or valvular defect.
27. The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth) 0.4 rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml 28. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? Auscultate the client's bowel sounds Observe for edema around the ankles Measure the client’s capillary glucose level Count the apical and radial pulses simultaneously Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes constipation, so it is most important to Auscultate the client's bowel sounds 29. A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants ―no heroic measures‖ taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement? Ask the client to discuss ―do not resuscitate‖ with her healthcare provider 30. A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour 31. A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask? Have you noticed any changes in your fingernails? Rationale: The pattern of reported manifestations is suggestive of hypothyroidism 32. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? Capillary refill of 8 seconds bruises on arms and legs
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) round and tight abdomen pitting edema in lower legs 33. After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse’s signature on the client’s surgical consent form? (Select all that apply) The client voluntarily grants permission for the procedure to be done The client is competent to sign the consent without impairment of judgment The client understands the risks and benefits associated with the procedure 34. Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? Advise the client that assignments are not based on clients requests 35. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? Place the implant in a lead container using long-handled forceps 36. The client with which type of wound is most likely to need immediate intervention by the nurse? Laceration Abrasion Contusion Ulceration
Rationale: A laceration is a wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and debris from whatever object caused the cut.
37. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client’s plan of care? Monitor blood pressure frequently
Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-threatening hypertension. The tumor is malignant in 10% of cases but may be cured completely by surgical removal. Although pheochromocytoma has classically been associated with 3 syndromes—von Hippel-Lindau (VHL) syndrome, multiple endocrine neoplasia type 2 (MEN 2), and neurofibromatosis type 1 (NF1)—there are now 10 genes that have been identified as sites of mutations leading to pheochromocytoma.
38. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? To reduce abdominal pressure on the diaphragm to promote retraction of the intercostal accessory muscle of respiration to promote bronchodilation and effective airway clearance to decrease pressure on the medullary center which stimulates breathing Rationale: a semi-sitting position is the best position for matching ventilation and perfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 39. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? The client is too obese Palpating in the wrong abdominal quadrant Deeper palpation technique is needed The gallbladder is normal Rationale: a normal healthy gallbladder is not palpable 40. A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? describe the transmission of drugs to the infant through breast milk encourage her to use stress relieving alternatives, such as deep breathing exercises Inform her that some antianxiety medications are safe to take while breastfeeding Explain that anxiety is a normal response for the mother of a 3-week-old. Rationale: there are several antianxiety medications that are not contraindicated for breastfeeding mothers. 41. An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? Start an intravenous (IV) infusion of normal saline obtain a serum potassium level administer the client's usual dose of insulin assess pupillary response to light Rationale: the nurse should first start an intravenous infusion of normal saline to replace the fluids and electrolytes because the client has been vomiting, and it is unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting, and abdominal cramping are all suggestive of hyperglycemia, which also contributes to diuresis and fluid electrolyte imbalance. 42. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medication? increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure the antagonistic interaction among the various blood pressure medications has reduced their effectiveness The additive effect of multiple medications has caused the blood pressure to drop too low the synergistic effect of the multiple medications has resulted in drug toxicity and
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) resulting hypotension 43. Which client is at the greatest risk for developing delirium? An adult client who cannot sleep due to constant pain. an older client who attempted 1 month ago a young adult who takes antipsychotic medications twice a day a middle-aged woman who uses a tank for supplemental oxygen 44. Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? Reduce risks factors for infection Administer high flow oxygen during sleep Limit fluid intake to reduce secretions Use diaphragmatic breathing to achieve better exhalation 45. Which location should the nurse choose as the best for beginning a screening program for hypothyroidism? A business and professional women's group. An African-American senior citizens center A daycare center in a Hispanic neighborhood An after-school center for Native-American teens 46. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling ―very tired‖. Which nursing intervention is most important for the nurse to implement? Measure vital signs Auscultate breath sounds Palpate the abdomen Observe the skin for bruising 47. A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider? capillary glucose urine specific gravity Serum calcium white blood cell count 48. What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? working together can decrease the risk for back injury The technique is intended to maintain straight spinal alignment. Using two or three people increases client safety. turning instead of pulling reduces the likelihood of skin damage 49. A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client? Baked apples topped with dried raisins 50. Which action should the school nurse take first when conducting a screening for scoliosis? Inspect for symmetrical shoulder height. 51. An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) the charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse implement? Assign a practical nurse (LPN) to determine if an apical radial deficit is present 52. After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client’s discharge plan? Encourage a low-carbohydrate and high-protein diet 53. A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform? Observe the antecubital fossa for inflammation. 54. The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication’s effectiveness, which laboratory values should the nurse monitor? Select all that apply White blood cell (WBC) count Sputum culture and sensitivity 55. A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement? Negative pressure environment contact precautions droplet precautions protective environment 56. A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child? Sitting up and leaning forward 57. A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? Altered consciousness within the first 24 hours after injury. 58. A female client with breast cancer who completed her first chemotherapy treatment today at an out-patient center is preparing for discharge. Which behavior indicates that the client understands her care needs Rented movies and borrowed books to use while passing time at home 59. Which instruction should the nurse provide a pregnant client who is complaining of heartburn? Eat small meal throughout the day to avoid a full stomach. 60. A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? Hypokalemia Ketonuria. Peripheral edema Elevated blood pressure Rational: pituitary tumors that suppress antidiuretic hormone (ADH) result in
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) diabetes insipidus, which causes massive polyuria and serum electrolyte imbalances, including hypokalemia, which can lead to lethal arrhythmias. 61. A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement? Digitally check the client for a fecal impaction 62. After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse? Bilateral Wheezing. 63. The nurse should teach the parents of a 6 year-old recently diagnosed with asthma that the symptom of acute episode of asthma are due to which physiological response? Inflammation of the mucous membrane & bronchospasm 64. A 10 year old who has terminal brain cancer asks the nurse, "What will happen to my body when I die?" How should the nurse respond? "The heart will stop beating & you will stop breathing." 65. The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply: Restlessness Clenched Fist Increased pulse rate Increased respiratory rate. Increased temperature Peripheral pallor of the skin 66. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication? Determine which side of the body is weak. 67. The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse? Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing. Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-pratt drain. Collapsed lung after a fall 8h ago with 100 ml blood in the chest tube collection container Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills. Rationale: the client with an abdominal- perineal resection is at risk for peritonitis and needs to be immediately assessed for other signs and symptoms for sepsis. 68. The nurse is caring for a client who had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours? Measure hourly urinary output. Rationale: a serious early complications of gastric bypass surgery is an anastomoses leak, often resulting in death.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 69. When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement? Schedule an appointment for an out-patient psychosocial assessment. 70. An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first? Explore client’s readiness to discuss the situation. 71. In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor? Lactate Glucose Hemoglobin Creatinine 72. Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client? Use two forms of contraception while taking this drug. 73. A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it is most important for the nurse to review the laboratory value for which medication? Divalproex. Rationale: divalproex is the first line of treatment for bipolar disorder BPD because it has a high therapeutic index, few side effects, and a rapid onset in controlling symptoms and preventing recurrent episodes of mania and depression. The serum value of divalproex should be determined since the client is exhibiting symptoms of mania, which may indicate non-compliance with the medication regimen. 74. A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? Serum lithium level of 1.6 mEq/L or mmol/l (SI) Rationale: The therapeutic level of Serum lithium is 0.8 to 1.5 mEq/L or mmol/l (SI). Slurred speech and ataxia are sign of lithium toxicity. 75. A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client’s EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, ―I feel like an elephant just stepped on my chest‖ The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform? Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula. 76. The nurse is developing a teaching program for the community. What population characteristic is most influential when choosing strategies for implementing a teaching plan?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) Literacy level 77. A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet? Eat approximated the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. 78. A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention. Maintain contact transmission precaution
79. A postoperative female client has a prescription for morphine sulfate 10 mg IV q3 hours for pain. One dose of morphine was administered when the client was admitted to the post anesthesia care unit (PACU) and 3 hours later, the client is again complaining of pain. Her current respiratory rate is 8 breaths/minute. What action should the nurse take? Administer Naxolone IV 80. Which intervention is most important for the nurse to include in the plan of care for an older woman with osteoporosis? Place the client on fall precautions 81. Based on the information provided in this client’s medical record during labor, which should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.) Continue to monitor the progress of labor. 82. An unlicensed assistive personnel UAP leaves the unit without notifying the staff. In what order should the unit manager implement this intervention to address the UAPs behavior? (Place the action in order from first on top to last on bottom.) 1. Note date and time of the behavior. 2. Discuss the issue privately with the UAP. 3. Plan for scheduled break times. 4. Evaluate the UAP for signs of improvement. 83. A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer’s at 100 ml/H. which finding is most important for the nurse to report to the healthcare provider? Serum potassium level of 3.1 mEq/L or mmol/L (SI) Rationale: The normal potassium level in the blood is 3.5-5.0 milliEquivalents per liter (mEq/L). 84. Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms? Neutrophils Lymphocytes Eosinophils Monocytes
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Rationale: Eosinophils are involved in allergic responses and destruction of parasitic worms. 85. The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat? Yogurt and/or buttermilk. 86. Several months after a foot injury, and adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will ―finally go away.‖ How should the nurse respond? Assist the client in developing a goal of managing the pain 87. One day following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of ―a tingly sensation‖ in his left foot. The nurse determines the client’s left pedal pulses are diminished. Based on these finding, what is the client’s greatest risk? Neurovascular and circulation compromise related to compartment syndrome. 88. The nurse is completing a head to be assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse? Clear fluid leaking from the nose. 89. A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath (Uhthoff’s sign). Which pathophysiological mechanism supports this response? Temporary vasodilation 90. While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion site. What interventions should the nurse implement? Promptly remove the arterial catheter from the radial artery. 91. A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor? Rapid onset of decreased level of consciousness. 92. The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement? Position a firm wedge to support pelvis and thorax at 30 degree tilt. 93. When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client’s discharge teaching plan? Report any signs of cloudy urine output. 94. For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action? Tented skin turgor. 95. After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching, what action should the nurse take? Apply light pressure over the area. 96. The nurse enters a client’s room and observes the client’s wrist restraint secured as seen in the picture. What action should the nurse take? Reposition the restraint tie onto the bedframe.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 97. A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants immediate intervention by the nurse? Diminished left lower lobe sounds Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax, which required immediate chest tube insertion to re-inflate the lung. 98. The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological events in orders of occurrence. (Place the first event on top and the last on the bottom) 1. Arterial endothelium injury causes inflammation 2. Macrophages consume low density lipoprotein (LDL), creating foam cells 3. Foam cells release growth factors for smooth muscle cells 4. Smooth muscle grows over fatty streaks creating fibrous plaques 5. Vessel narrowing results in ischemia 99. Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse’s decision to report this finding to the healthcare provider? Oliguria signals tubular necrosis related to hypoperfusion 100. A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective? Skills of staff and client acuity 101. When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use? Explain that the client may be placed in five positions 102. A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell’s palsy rather than a stroke? Inability to close the affected eye, raise brow, or smile 103. The nurse is teaching a client how to perform colostomy irrigations. When observing the client’s return demonstration, which action indicated that the client understood the teaching? Keeps the irrigating container less than 18 inches above the stoma 104. The nurse should teach the client to observe which precaution while taking dronedarone? Avoid grapefruits and its juice 105. A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse include the client’s risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased? Increased Glasgow coma scale score. Nuchal rigidity and papilledema.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Confusion and papilledema Periorbital ecchymosis. Rationale: papilledema is always an indicator of increased ICP, and confusion is usually the first sign of increased ICP. Other options do not necessarily reflect increased ICP. 106. The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection? Confirm the necessity for continued use of the CVC. 107. During an annual physical examination, an older woman’s fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)? Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI). 108. A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. What action should the nurse take? Determine if she can ask for support from family, friend, or the baby’s father. 109. A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first? Stop the normal saline infusion. 110. An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck’s skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client’s plan care? Ensure proper alignment of the leg in traction. 111. An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding? Document the ongoing wound healing. 112. At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, ―I just know I can’t handle all the pain.‖ What is the priority nursing diagnosis for this client? Anxiety 113. The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately? Elevate the presenting part off the cord. 114. A client who had a right hip replacement 3 day ago is pale has diminished breath sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client’s symptoms, what recommendation should the nurse give the healthcare provider? Reassess readiness for SNF transfer. 115. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client’s teaching plan? (Select all that apply.) Recognize signs and symptoms of hypoglycemia. Report persist polyuria to the healthcare provider. Take Glucophage with the morning and evening meal. 116. The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? Select all that apply Written at a twelfth grade reading level Contains a list with definitions of unfamiliar terms Uses common words with few Syllables Printed using a 12 point type font Uses pictures to help illustrate complex ideas Rationale: During the aging process older clients often experience sensory or cognitive changes, such as decreased visual or hearing acuity, slower thought or reasoning processes, and shorter attention span. Materials for this age group should include at least of terms, such as a medical terminology that incline may not know and use common words that expresses information clearly and simply. Simple, attractive pictures help hold the learner’s attention. The reading level of material should be at the 4th to 5th grade level. Materials should be printed using large font (18-point or higher), not the standard 12-point font. 117. During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client’s point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location)
118. 118.
An older male adult resident of long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.)
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Notify the healthcare provider of the client’s change in mental status. Include q2 hour’s reorientation in the client’s plan of care. 119. An older male comes to the clinic with a family member. When the nurse attempts to take the client’s health history, he does not respond to questions in a clear manner. What action should the nurse implement first? Assess the surroundings for noise and distractions. 120. The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need? Large amounts of fluid and electrolyte replacement. 121. Which intervention should the nurse include in the plan of care for a child with tetanus? Minimize the amount of stimuli in the room 122. 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? Remove cigarettes for the client’s room 123. 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 client must be willing to accept palliative care, not curative care. The healthcare provider must project that the client has 6 months or less to live. 124. A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client’s teaching plan? Avoid use of nonsteroidal ant-inflammatory drugs (NSAID). 125. A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse? A mother with an infected episiotomy 126. 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? Digoxin. 127. 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? Supervise a newly hired graduate nurse during an admission assessment. 128. 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? Ask the client what he is thinking about at his time. 129. 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.)
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Administer PRN nebulizer treatment. Obtain 12 lead electrocardiogram. Monitor continuous oxygen saturation. 130. 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? Administer a prescribed analgesia for pain. 131. 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? Use sunblock or protective clothing when outdoors. 132. 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? (Select all that apply) Notify the food services department of the allergy. Enter the allergy information in the client’s record. Add egg allergy to the client’s allergy arm band. 133. 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? Perform bilateral chest auscultation. 134. After administering an antipyretic medication. Which intervention should the nurse implement? Encouraging liberal fluid intake 135. A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment? Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider 136. 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? Determine client’s pulse, blood pressure, and respirations 137. 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) Take postoperative vital signs for a client who has an epidual following knee arthroplasty Collect a sputum specimen for a client with a fever of unknown origin Ambulate a client who had a femoral-popliteal bypass graft yesterday 138. 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? Raise the head of the bed to a Fowler’s position and support his arms with a
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) pillow 139. 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? Administer the analgesic as requested Rationale: Chronic pain may be difficult to describe but should be treated with analgesics as indicated. 140. A client with a chronic health problem has difficulty ambulating short distance due to generalized weakness, but is able to bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client? Crutches with 2 point gait. Crutches with 3 point gait.
Crutches with 4 point gait.
A quad cane
141. 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 value only.)
Answer: 12160
Rationale: 4ml x 67kg x 40 (bsa) =12,160 ml
142. A client with leukemia undergoes a bone marrow biopsy. The client’s laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?
Observe aspiration site.
Assess body temperature
Monitor skin elasticity
Measure urinary output
143. An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement?
Reinforce the importance of annual papanicolaou (Pap) smears.
144. A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?
Establish a structured routine for the client to follow.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 145. A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?
Ventricular arrhythmias.
Rationale: adrenal crisis, a potential complication of bilateral adrenalectomy, results in the loss of mineralocorticoids and sodium excretions that is characterized by hyponatremia, hyperkalemia, dehydration, and hypotension. Ventricular arrhythmias are life threatening and required immediate intervention to correct critical potassium levels.
146. The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement?
Instruct the mother to change the child’s diaper more often.
147. A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement?
Encourage the client to eat finger foods.
148. A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication?
Bowel patterns
Rationale: the client should be assessed for a change in bowel patterns to evaluate the effectiveness of this medication because Mesalamine is used to treat ulcerative colitis (a condition which causes swelling and sores in the lining of the colon [large intestine] and rectum) and also to maintain improvement of ulcerative colitis symptoms. Mesalamine is in a class of medications called anti-inflammatory agents. It works by stopping the body from producing a certain substance that may cause inflammation.
149. While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement?
Contact the medical records department supervisor.
150. A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
Answer 83
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Rationale: 1000 ml ---- 12hr.
Xml --------- 1hr.
1000/12 = 83.33 = 83.
151. While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first?
Submit a referral for an evaluation by a physical therapist.
152. A client has an intravenous fluid infusing in the right forearm. To determine the client’s distal pulse rate most accurately, which action should the nurse implement?
Palpate at the radial pulse site with the pads of two or three fingers.
153. A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement?
Reposition the client with the head of the bed elevated.
154. A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take?
Ask the older brother how he felt during the incident.
155. After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement?
Hold oral intake until swallow evaluation is done.
156. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply)
Interacts with a flat affect.
Avoids eye contact.
Has a disheveled appearance.
157. A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete postanesthesia scoring system. What intervention should nurse implement?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Transfer the client to the surgical floor.
158. In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
Place personal religious artifacts on the body.
Attach identifying name tags to the body.
Follow cultural beliefs in preparing the body.
159. An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions?
Be alert for possible cross-sensitivity to cephalosporin agents.
160. A client with a prescription for ―do not resuscitate‖ (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement?
The client’s need for pain medication should be determined.
161. A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.)
Monitor abdominal girth.
Increase oral fluid intake to 1500 ml daily.
Report serum albumin and globulin levels.
Provide diet low in phosphorous.
Note signs of swelling and edema.
Rational: monitoring for increasing abdominal girth and generalized tissue edema and swelling are focused assessments that provide data about the progression of disease related complications. In advanced cirrhosis, liver function failure results in low serum albumin and serum protein levels, which caused third spacing that results in generalized fluid retention and ascites. Other options are not indicated in end stage liver disease.
162. During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?
Report weight gain of 2 pounds (0.9kg) in 24 hours
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 163. Which problem, noted in the client’s history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)?
Aural migraine headaches.
164. When implementing a disaster intervention plan, which intervention should the nurse implement first?
Initiate the discharge of stable clients from hospital units
Identify a command center where activities are coordinated
Assess community safety needs impacted by the disaster
Instruct all essential off-duty personnel to report to the facility
165. The nurse is evaluating a client’s symptoms, and formulates the nursing diagnosis, ―high risk for injury due to possible urinary tract infection.‖ Which symptoms indicate the need for this diagnosis?
Fever and dysuria.
166. A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement?
Maintain both lower extremities elevated on pillows.
167. A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client’s plan of care?
Teach family proper range of motion exercises.
168. The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention?
Postmenopausal women need an intake of at least 1,500 mg of calcium daily.
169. When evaluating a client’s rectal bleeding, which findings should the nurse document?
Color characteristics of each stool.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 170. The nurse is auscultating a client’s lung sounds. Which description should the nurse use to document this sound?
High pitched or fine crackles.
Rhonchi
High pitched wheeze
Stridor
171. An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement?
Explain the reason for using only non-narcotics.
172. The nurse is managing the care of a client with Cushing’s syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)
Weigh the client and report any weight gain.
Report any client complaint of pain or discomfort.
Note and report the client’s food and liquid intake during meals and snacks.
173. Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client’s plan of care?
Medicate as needed for pain and anxiety.
174. An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries?
Decrease prevalence of glaucoma in the population.
175. The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first?
Convey to the client that birth is imminent.
176. To evaluate the effectiveness of male client’s new prescription for ezetimibe, which action should the clinic nurse implement?
Remind the client to keep his appointments to have his cholesterol level checked.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 177. Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include? 178.
Fall prevention measures.
179. A young adult client is admitted to the emergency room following a motor vehicle collision. The client’s head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as ‖ Risk of injury‖ What term best expresses the ―related to‖ portion of nursing diagnosis?
Infection
Increase intracranial pressure
Shock
Head Injury.
180. An older male client with history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first?
Identify pills in the bag.
181. A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider?
New onset of purple skin lesions.
182. In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement?
Ensure that no dependent loops are present in the tubing.
183. The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat?
Yogurt and/or buttermilk.
Avocados and cheese
Green leafy vegetables
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Fresh fruits
184. The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN?
An adult female who has been depress for the past several month and denies suicidal ideations.
A middle-age male who is in depressive phase on bipolar disease and is receiving Lithium.
A young male with schizophrenia who said voices is telling him to kill his psychiatric.
An elderly male who tell the staff and other client that he is superman and he can fly.
Rationale: The RN should deal with the client with command hallucinations and these can be very dangerous if the client’s acts on the commands, especially if the command is a homicidal in nature. Other client present low safety risk.
185. A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the nurse withhold the next dose of this drug?
Maternal pulse rate of 162 beats per min
186. In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client’s appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis?
Anxiety related to fear of suffocation.
187. A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client’s a plan of care?
Provide daily care of tong insertion sites using saline and antibiotic ointment
188. A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first?
Determine the client’s vital sign.
189. A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) after the admission assessment, should the nurse report immediately to the emergency department healthcare provider? 190.
No wheezing upon auscultation of the chest.
191. The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation?
During acute illness
192. A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs?
Tell all their assigned clients to stay in their rooms.
193. The nurse is auscultating is auscultating a client’s heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.)
Murmur
s1 s2
pericardial friction rub
s1 s2 s3
194. The healthcare provider changes a client’s medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement?
Administer the medication via the oral route as prescribed
195. A client refuses to ambulate, reporting abdominal discomfort and bloating caused by ―too much gas buildup‖ the client’s abdomen is distended. Which prescribed PRN medication should the nurse administer?
Simethicone (Mylicon)
196. The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse’s proposal?
Case management and screening for clients with HIV.
Regional relocation center for earthquake victims
Vitamin supplements for high-risk pregnant women.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Lead screening for children in low-income housing.
Rational: Primary prevention activities focus on health promotions and disease preventions, so vitamin for high-risk pregnant women provide adequate vitamin and mineral for fetal developmental.
197. When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement?
Arrange to transport the client to the hospital
Instruct the client to keep a food journal, including portions size.
Review the client’s use of over the counter (OTC) medications.
Reinforce the importance of keeping the feet elevated.
Rationale: Sodium is used in several types of OTC medications. Including antacids, which the client may be using to treat his GERD. Further evaluation is need it to determine the need for hospitalization (A) A food journal (B) may help over, but dietary modifications are needed now since edema is present. (C) May relieve dependent edema, but not treat the underlying etiology.
198. An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition?
Multiple organ dysfunction syndrome (MODS)
Disseminated intravascular coagulation (DIC)
Chronic obstructive disease.
Acquired immunodeficiency syndrome (AIDS)
Rational: MODS are a progressive dysfunction of two or more major organs that requires medical intervention to maintain homeostasis. This client has evidence of several organ systems that require intervention, such as blood pressure, hemoglobin, WBC, and respiratory rate. DIC may develop as a result of MODS. The other options are not correct.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 199. A man expresses concern to the nurse about the care his mother is receiving while hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take?
Provide the man and his mother with a copy of the Patient’s Bill of Rights
200. A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action?
Administer naloxone (Narcan) per PNR protocol
Initiate seizure precautions
Obtain a serum drug screen
Instruct the family about withdrawal symptoms.
Rationale: Withdrawal of CNS depressants, such as Xanax, results in rebound over-excitation of the CNS. Since the client exhibiting tremors, the nurse should anticipate seizure activity and protect the client.
201. The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose?
Jaundice
Nausea
Fever
Fatigue
202. A client with Alzheimer’s disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client’s mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information?
Explain that it may take several weeks for the medication to be effective
Confirm the desired effect of the medication has been achieved.
Notify the health care provider than a change may be needed.
Evaluate when and how the medication is being administered to the client.
Rationale: Trazodone o Desyrel, an atypical antidepressant, is prescribed for client with AD to improve mood and sleep.
203. A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Reduced level of pain
Full volume of pedal pulses
Granulating tissue in foot ulcer
Improved visual acuity
204. A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization’s budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?
How many departments can use this equipment?
Will the equipment require annual repair?
Is the cost of the equipment reasonable?
Can the equipment be updated each year?
205. While receiving a male postoperative client’s staples de nurse observe that the client’s eyes are closed and his face and hands are clenched. The client states, ―I just hate having staples removed‖. After acknowledgement the client’s anxiety, what action should the nurse implement?
Encourage the client to continue verbalize his anxiety
Attempt to distract the client with general conversation
Explain the procedure in detail while removing the staples
Reassure the client that this is a simple nursing procedure.
Rational: Distract is an effective strategy when a client experience anxiety during an uncomfortable procedure. (A & D) increase the client’s anxiety.
206. A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.)
Collect multiple site screening culture for MRSA
Call healthcare provider for a prescription for linezolid (Zyrovix)
Place the client on contact transmission precautions
Obtain sputum specimen for culture and sensitivity
Continue to monitor for client sign of infection.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Rationale: Until multi-site screening cultures come back negative (A), the client should be maintained on contact isolation(C) to minimize the risk for nosocomial infection. Linezolid (Zyvox), a broad spectrum anti-infectant, is not indicated, unless the client has an active skin structure infection cause by MRSA or multidrug- resistant strains (MDRSP) of Staphylococcus aureus. A sputum culture is not indicated9D) based on the client’s history is a wound infection.
207. A vacuum-assistive closure (VAC) device is being use to provide wound care for a client who has stage III pressure ulcer on a below-the- knee (BKA) residual limb. Which intervention should the nurse implement to ensure maximum effectiveness of the device?
Ensure the transparent dressing has no tears that might create vacuum leaks
208. The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of ―Ineffective airway clearance related to thick pulmonary secretions.‖ Which intervention is most important for the nurse to include in the client’s plan of care?
Increase fluid intake to 3,000 ml/daily
209. The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?
Clearance around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle
Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours.
For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens.
Urinate immediately into a urinal, and the lab will collect specimen every 6 hours, for the next 24 hours.
Rationale: Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours is the correct procedure for collecting 24-hour urine specimen. Discarding even one voided specimen invalidate the test.
210. The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification?
Decreases the amount of HCL secretion by the parietal cells in the stomach
211. The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator of the drug’s effectiveness?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Hemoglobin A1C (HbA1C) reading less than 7%
212. The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication?
Antibiotics
Anticoagulants
Antihypertensive
Anticholinergics
213. A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant’s plan of care?
Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90%
Administer diuretics via secondary infusion in the morning only
Evaluate heart rate for effectiveness of cardio tonic medications
Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples
Ensure Interrupted and frequent rest periods between procedures.
Rationale: Pulse oximetry screening supports prescribed level of O2. HR provides an evaluative criterion for cardiac medications, which reduce heart rate, increase strength contractions (inotropic effects) and consequently affect systemic circulation and tissue oxygenation. Breast milk or basic formula provide 20 calories/ounce, so frequent feedings with high energy formula. D minimize fatigue is necessary.
214. The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.) 1. Start chest compressions with assisted manual ventilations 2. Administer epinephrine 0.01 mg/kg intraosseous (IO) 3. Apply pads and prepare for transthoracic pacing 4. Review the possible underlying causes for bradycardia 215. An elderly male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition?
Delirium
Depression
Dementia
Psychotic episode
216. Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? Select all that apply.
Prepare medication reversal agent
Check oxygen saturation level
Apply oxygen via nasal cannula
Initiate bag- valve mask ventilation.
Begin cardiopulmonary resuscitation
Rationale: Sedation, given during the procedure may need to be reverse if the client does not easily wake up. Oxygen saturation level should be asses, and oxygen applied to support respiratory effort and oxygenation. The client is still breathing so the bag- valve mask ventilation and CPR are not necessary.
217. The nurse is planning preoperative teaching plan of a 12-years old child who is scheduled for surgery. To help reduce the child anxiety, which action is the best for the nurse to implement?
Give the child syringes or hospital mask to play it at home prior to hospitalization.
Include the child in pay therapy with children who are hospitalized for similar surgery.
Provide a family tour of the preoperative unit one week before the surgery is scheduled.
Provide doll an equipment to re-enact feeling associated with painful procedures.
Rationale: School age children gain satisfaction from exploring and manipulating their environment, thinking about objectives, situations and events, and making judgments based on what they reason. A tour of the unit allows the child to see the hospital environment and reinforce explanation and conceptual thinking.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 218. Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client’s arm?
Assess IV site frequently for signs of extravasation
219. When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur?
Resume normal physical activity
Drink electrolyte fluid replacement
Give a dose of regular insulin per sliding scale
Measure urinary output over 24 hours.
Rationale: As hyperglycemia persist, ketone body become a fuel source, and the client manifest early signs of DKA that include excessive thirst, frequent urination, headache, nausea and vomiting. Which result in dehydration and loss of electrolyte. The client should determine fingersticks glucose level and selfadminister a dose of regular insulin per sliding scale.
220. The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize?
Protect joint function
Improve circulation
Control tremors
Increase weight bearing
221. An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)?
9 %
18 %
36 %
45 %
Rational: according to the rule of nines, the anterior and posterior surfaces of one lower extremity is designated as 18 %of total body surface area (TBSA), so both extremities equals 36% TBSA, other options are incorrect.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 222. A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect?
Decrease in serum T4 levels
Increase in blood pressure
Decrease in pulse rate
Goiter no longer palpable
223. An older male client with type 2 diabetes mellitus reports that has experiences legs pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation?
Consistently applies TED hose before getting dressed in the morning.
Frequently elevated legs thorough the day.
Inspect the leg frequently for any irritation or skin breakdown
Completely stop cigarette/ cigar smoking.
Rationale: Stopping cigarette smoking helps to decrease vasoconstriction and improve arterial circulation to the extremity.
224. A community health nurse is concerned about the spread of communicable diseases among migrant farm workers in a rural community. What action should the nurse take to promote the success of a healthcare program designed to address this problem?
Establish trust with community leaders and respect cultural and family values
225. The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client’s Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine?
The client’s previous GCS score
When the client’s stroke symptoms started
If the client is oriented to time
The client’s blood pressure and respiration rate
Rationale: The normal GCS is 15, and it is most important for the nurse to determine if it abnormal score a sign of improvement or a deterioration in the client’s condition
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 226. The charge nurse in a critical care unit is reviewing clients’ conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit?
Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation
227. Based on principles of asepsis, the nurse should consider which circumstance to be sterile?
One inch- border around the edge of the sterile field set up in the operating room
A wrapped unopened, sterile 4x4 gauze placed on a damp table top.
An open sterile Foley catheter kit set up on a table at the nurse waist level
Sterile syringe is placed on sterile area as the nurse riches over the sterile field.
Rationale: A sterile package at or above the waist level is considered sterile. The edge of sterile field is contaminated which include a 1-inch border (A). A sterile objects become contaminated by capillary action when sterile objects become in contact with a wet contaminated surface.
228. An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take?
Ask the UAP to take the blood pressure in the other arm
Tell the UAP to use a different sphygmomanometer.
Review the client’s serum calcium level
Administer PRN antianxiety medication.
Rationale: Trousseau’s sign is indicated by spasms in the distal portion of an extremity that is being used to measure blood pressure and is caused by hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented.
229. A 56-years-old man shares with the nurse that he is having difficulty making decision about terminating life support for his wife. What is the best initial action by the nurse?
Provide an opportunity for him to clarify his values related to the decision
Encourage him to share memories about his life with his wife and family
Advise him to seek several opinions before making decision
Offer to contact the hospital chaplain or social worker to offer support.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Rationale: When a client is faced with a decisional conflict, the nurse should first provide opportunities for the client to clarify values important in the decision. The rest may also be beneficial once the client as clarified the values that are important to him in the decision-making process.
230. A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this client’s discharge teaching plan?
Weigh every morning
Eat a high protein diet
Perform range of motion exercises
Limit fluid intake to 1,500 ml daily
231. A woman just learned that she was infected with Heliobacter pylori. Based on this finding, which health promotion practice should the nurse suggest?
Encourage screening for a peptic ulcer
232. A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan?
Teach tracheal suctioning techniques
233. A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain?
Cardiac rhythm and heart rate.
Daily intake of foods rich in potassium.
Hourly urinary output
Thirst ad skin turgor.
234. The nurse note a depressed female client has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?
Encourage the client’s family to visit more often
Schedule a daily conference with the social worker
Encourage the client to participate in group activities
Engage the client in a non-threatening conversation.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Rationale: Consistent attempts to draw the client into conversations which focus on non-threatening subjects can be an effective means of eliciting a response, thereby decreasing isolation behaviors. There is not sufficient data to support the effectiveness of A as an intervention for this client. Although B may be indicated, nursing interventions can also be used to treat this client. C is too threatening to this client.
235. A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel) subcutaneously once weekly. The nurse should emphasize the importance of reporting problem to the healthcare provider?
Headache
Joint stiffness
Persistent fever
Increase hunger and thirst
Rationale: Enbrel decrease immune and inflammatory responses, increasing the client’s risk of serious infection, so the client should be instructed to report a persistent fever, or other signs of infection to the healthcare provider.
236. The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment finding indicates that the client understands long- term control of diabetes?
The fating blood sugar was 120 mg/dl this morning.
Urine ketones have been negative for the past 6 months
The hemoglobin A1C was 6.5g/100 ml last week
No diabetic ketoacidosis has occurred in 6 months.
Rationale: A hemoglobin A1C level reflects he average blood sugar the client had over the previous 2 to 3 month, and level of 6.5 g/100 ml suggest that the client understand long-term diabetes control. Normal value in a diabetic patient is up to 6.5 g/100 ml.
237. An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client’s wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take?
Ask the wife to stop and assess the client’s swallowing reflex
238. A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects home aspirate specimens
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) for culture and sensitivity and applies a cast to the adolescent’s lower leg. What action should the nurse implement next?
Administer antiemetic agents
Bivalve the cast for distal compromise
Provide high- calorie, high-protein diet
Begin parenteral antibiotic therapy
Rationale: The standard of treatment for osteomyelitis is antibiotic therapy and immobilization. After bond and blood aspirate specimens are obtained for culture and sensitivity, the nurse should initiate parenteral antibiotics as prescribed.
239. The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation?
Recommend weigh bearing physical activity
240. 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. What action should the nurse implement next?
Administer the analgesic as requested
241. A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement?
Send stool sample to the lab for a guaiac test
Observe stool for a day-colored appearance.
Obtain specimen for culture and sensitivity analysis
Asses for fatty yellow streaks in the client’s stool.
Rationale: Thrombolytic drugs increase the tendency for bleeding. So guaiac (occult blood test) test of the stool should be evaluated to detect bleeding in the intestinal tract.
242. The mother of a child with cerebral palsy (CP) ask the nurse if her child’s impaired movements will worsen as the child grows. Which response provides the best explanation?
Brain damage with CP is not progressive but does have a variable course
243. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 244.
Respiratory apnea of 30 seconds In early septic shock states, what is the primary cause of hypotension?
Peripheral vasoconstriction
Peripheral vasodilation
Cardiac failure
A vagal response
Rationale: Toxins released by bacteria in septic shock create massive peripheral vasodilation and increase microvascular permeability at the site of the bacterial invasion.
245. A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider’s attention?
Allopurinol (Zyloprim)
Aspirin, low dose
Furosemide (lasix)
Enalapril (vasote)
246. A male client’s laboratory results include a platelet count of 105,000/ mm3 Based on this finding the nurse should include which action in the client’s plan of care?
Cluster care to conserve energy
Initiate contact isolation
Encourage him to use an electric razor
Asses him for adventitious lung sounds
Rationale: This client is at risk for bleeding based on his platelet count (normal 150,000 to 400,000/ mm3). Safe practices, such as using an electric razor for shaving, should be encouraged to reduce the risk of bleeding.
247. A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding?
Abnormal responses for cranial nerves I and II
Persistent coughing while drinking
Unilateral facial drooping
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Inappropriate or exaggerated mood swings
248. At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client’s medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation:
Remove sequential compression devices.
Apply PRN oxygen per nasal cannula.
Administer a PRN dose of an antipyretic.
Reinforce the surgical wound dressing.
Rationale: Sequential compression devices should be removed prior to ambulation and there is no indication that this action is contraindicated. The client’s oxygen saturation levels have been within normal limits for the previous four hours, so supplemental oxygen is not warranted.
249. Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider?
Sudden dysphagia
Blurred visual field
Gradual weakness
Profuse diarrhea
250. A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take?
Ask a chemotherapy-certified nurse to administer the Zofran
Administer the Zofran after flushing the saline lock with saline
Hold the scheduled dose of Zofran until the client awakens
Awaken the client to assess the need for administration of the Zofran.
Rationale: Zofran is an antiemetic administered before and after chemotherapy to prevent vomiting. The nurse should administer the antiemetic using the accepter technique for IV administration via saline lock. Zofran is not a chemotherapy drug and does not need to be administered by a chemotherapy- certified nurse.
251. When providing diet teaching for a client with cholecystitis, which types of food choices the nurse recommend to the client?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
High protein
Low fat
Low sodium
High carbohydrate.
Rationale: A client with cholecystitis is at risk of gall stones that can be move into the biliary tract and cause pain or obstruction. Reducing dietary fat decrease stimulation of the gall bladder, so bile can be expelled, along with possible stones, into the biliary tract and small intestine.
252. A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse?
Jaundice skin tone
Muffled heart sounds
Pitting peripheral edema
Bilateral scleral edema
Rationale: Muffled heart sounds may indicative fluid build-up in the pericardium and is life- threatening. The other one are signs of end stage liver disease related to alcoholism but are not immediately life- threatening.
253. When entering a client’s room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take next?
Prepare to administer atropine 0.4 mg IVP
Gather emergency tracheostomy equipment
Prepare to administer lidocaine at 100 mg IVP
Place cardiac monitor leads on the client’s chest.
Rationale: Before further interventions can be done, the client’s heart rhythm must be determined. This can be done by connecting the client to the monitor. A or C are not a first line drug given for any of the life threatening, pulses dysrhythmias
254. A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Replace the IV site with a smaller gauge.
Redress the abdominal incision
Leave the lights on in the room at night.
Apply soft bilateral wrist restraints.
Rationale: The abdominal incision should be redressed using aseptic-techniques. The IV site should be assessed to ensure that it has not been dislodged and a dressing reapplied, if need it. Leaving the light on at night may interfere with the client’s sleep and increase confusion. Restraints are not indicated and should only be used as a last resort to keep client from self-harm.
255. An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest that the client is experiencing increased intracranial pressure (ICP)?
Lethargy
Decorticate posturing
Fixed dilated pupil
Clear drainage from the ear.
Rationale: Lethargy is the earliest sign of ICP along with slowing of speech and response to verbal commands. The most important indicator of increase ICP is the client’s level or responsiveness or consciousness. B and C are very late signs of ICP.
256. In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management?
Prepare the client to independently treat their disease process
Reduce healthcare costs related to diabetic complications
Enable clients to become active participating in controlling the disease process
Increase client’s knowledge of the diabetic disease process and treatment options.
Rationale: The primary goal of diabetic self- management education is to enable the client to become an active participant in the care and control of disease process, matching levels of self- management to the abilities of the individual client. The goal is to place the client in a cooperative or collaborative role with healthcare professional rather than (A)
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 257. To reduce staff nurse role ambiguity, which strategy should the nurse manager implemented?
Confirm that all the staff nurses are being assigned to equal number of clients.
Review the staff nurse job description to ensure that it is clear, accurate, and recurrent.
Assign each staff nurse a turn unit charge nurse on a regular, rotating basis.
Analyze the amount of overtime needed by the nursing staff to complete assignments.
Rationale: Role ambiguity occurs when there is inadequate explanation of job descriptions and assigned tasks, as well as the rapid technological changes that produce uncertainty and frustration. A and D may be implemented if the nurse manager is concerned about role overload, which is the inability to accomplish the tasks related to one’s role. C is not related to ambiguity.
258. The nurse is assisting a new mother with infant feeding. Which information should the nurse provide that is most likely to result in a decrease milk supply for the mother who is breastfeeding?
Supplemental feedings with formula
Maternal diet high in protein
Maternal intake of increased oral fluid
Breastfeeding every 2 or 3 hours.
Rationale: Infant sucking at the breast increases prolactin release and proceeds a feedback mechanism for the production of milk, the nurse should explain that supplemental bottle formula feeding minimizes the infant’s time at the breast and decreases milk supply. B promotes milk production and healing after delivery. C support milk production. C is recommended routine for breast feeding that promote adequate milk supply.
259. Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity?
Range of Motion
Distal pulse intensity
Extremity sensation
Presence of exudate
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Rationale: Distal pulse intensity assesses the blood flow through the extremity and is the most important assessment because it provides information about adequate circulation to the extremity. Range of motions evaluates the possibility of long term contractures sensation. C evaluates neurological involvement, and exudate. D provides information about wound infection, but this assessment do not have the priority of determining perfusion to the extremity.
260. An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse’s response should be based on which information about assistive devices?
They decrease the risk for joint trauma
261. When assessing a 6-month old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant?
Crying
Straining on stool
Vomiting
Sitting upright.
Rationale: The anterior fontanel closes at 9 months of age and may bulge when venous return is reduced from the head, but a bulging anterior fontanel is most significant if the infant is sitting up and may indicated an increase in cerebrospinal fluid. Activities that reduce venous return from the head, such as crying, a Valsalva maneuver, vomiting or a dependent position of the head, cause a normal transient increase in intracranial pressure.
262. A client with angina pectoris is being discharge from the hospital. What instruction should the nurse plan to include in this discharge teaching?
Engage in physical exercise immediately after eating to help decrease cholesterol levels.
Walk briskly in cold weather to increase cardiac output
Keep nitroglycerin in a light-colored plastic bottle and readily available.
Avoid all isometric exercises, but walk regularly.
Rationale: Isometric exercise can raise blood pressure for the duration of the exercise, which may be dangerous for a client with cardiovascular disease, while walking provides aerobic conditioning that improves ling, blood vessel, and muscle function. Client with angina should refrain from physical exercise for 2 hours after meals, but exercising does not decrease cholesterol levels. Cold water cause vasoconstriction that may cause chest pain. Nitroglycerin should be readily
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) available and stored in a dark-colored glass bottle not C, to ensure freshness of the medication. 263. What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump?
Initiate the dosage lockout mechanism on the PCA pump
Instruct the client to use the medication before the pain becomes severe
Assess the abdomen for bowel sounds.
Assess the client ability to use a numeric pain scale
264. While undergoing hemodialysis, a male client suddenly complains of dizziness. He is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128 beats/minute, respirations 18 breaths/minute, and blood pressure 90/60. Which intervention should the nurse implement first?
Raise the client’s legs and feet
265. The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn’s survival?
Heat loss
Hypoglycemia
Fluid balance
Bleeding tendencies
266. The fire alarm goes off while the charge nurse is receiving the shift report. What action should the charge nurse implement first?
Tell the staff to keep all clients and visitors in the client rooms with the doors closed
267. A 60-year-old female client asks the nurse about hormones replacement therapy (HRT) as a means preventing osteoporosis. Which factor in the client’s history is a possible contraindication for the use of HRT?
Her mother and sister have a history of breast cancer
268. A male client, who is 24 hours postoperative for an exploratory laparotomy, complains that he is ―starving‖ because he has had no ―real food‖ since before the surgery. Prior to advancing his diet, which intervention should the nurse implement?
Auscultate bowel sounds in all four quadrants
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 269. The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?
A family member of a client with dementia who has been missing for five hours
270. During change of shift, the nurse reports that a male client who had abdominal surgery yesterday increasingly confused and disoriented during the night. He wandered into other clients rooms, saying that there are men in his room trying to hurt him. Because of continuing disorientation and the client’s multiple attempts to get of bed, soft restrains were applied at 0400. In what order should the nurse who is receiving report implement these interventions? (Arrange from first action on top to last on the bottom). 1. Assess the client’s skin and circulation for impairment related to the restrains 2. Evaluate the client’s mentation to determine need to continue the restrains 3. Assign unlicensed assistive personnel to remove restrains and remain with client 4. Contact the client’s surgeon and primary healthcare provider 271. A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102 F. he is drooling and becoming increasingly more restless. What action should the nurse take first?
Notify the healthcare provider and obtain a tracheostomy tray
272. After receiving the first dose of penicillin, the client begins wheezing and has trouble breathing. The nurse notifies the healthcare provider immediately and received several prescriptions. Which medication prescription should the nurse administer first?
Epinephrine Injection, USP IV
273. Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first?
Evaluate both client’s pain using a standardized pain scale
274. A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take?
Administer the medication as prescribed with a glass of water
275. Which client should the nurse assess frequently because of the risk for overflow incontinence? A client
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Who is confused and frequently forgets to go to the bathroom
276. While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply)
Move obstacle away from client
Monitor physical movements
Observe for a patent airway
Record the duration of the seizure
277. A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client’s plan of care?
Determine client’s level current blood alcohol level.
Observe for changes in level of consciousness.
Involve the client’s family in healthcare decisions.
Provide grief counseling for client and his family.
Rationale: Based on the client’s history of drinking, he may be exhibiting sing of hepatic involvement and encephalopathy. Changes in the client’s level of consciousness should be monitored to determine if he able to maintain consciousness, so neurological assessment has the highest priority.
278. An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client’s ABG finding, which action is required?
Report the results to the healthcare provider.
Increase ventilator rate.
Administer a dose of sodium carbonate.
Decrease the flow rate of oxygen.
Rationale: This client is experience respiratory acidosis. Increasing the ventilator rate depletes CO2 a, which returns the PH toward normal. Report findings is important but only after increasing ventilator rate.
279. The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) a day, and has also experiences a loss of appetite. What instruction should the nurse provide?
Perform CPT after meals to increase appetite and improve food intake.
CPT should be performed more frequently, but at least an hour before meals.
Stop using CPT during the daytime until the child has regained an appetite.
Perform CPT only in the morning, but increase frequency when appetite improves.
Rationale: CPY with inhalation therapy should be performed several times a day to loosen the secretions and move them from the peripheral airway into the central airways where they can be expectorated. CPT should be done at least one hour before meals or two hours after meals.
280. The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendation for hypertension?
Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie
281. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client’s plan of care?
Fingerstick glucose assessment q6h with meals
Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose
Review with the client proper foot care and prevention of injury
Do not contaminate the insulin aspart so that it is available for iv use
Coordinate carbohydrate controlled meals at consistent times and intervals
Teach subcutaneous injection technique, site rotation and insulin management
282. Which problem reported by a client taking lovastatin requires the most immediate fallow up by the nurse?
Diarrhea and flatulence
Abdominal cramps
Muscle pain
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Altered taste
Rationale: statins can cause rhabdomyolysis, a potentially fatal disease of skeletal muscle characterized by myoglobinuria and manifested with muscle pain, so this symptom should immediately be reported to the HCP.
283. While assessing a client’s chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client’s vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement?
Provide supplemental oxygen
Auscultate bilateral lung fields
Administer a nebulizer treatment
Reinforce occlusive CT dressing
Give PRN dose of pain medication
Rationale: the air bubbles indicate an air leak from the lungs, the chest tube site, or the chest tube collection system. Providing oxygen improves the oxygen saturation until the leak has been resolved. Auscultating the lung fields helps to identify absent or decrease lung sound due to collapsing lung.
284. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?
Ensure that the knot can be quickly released.
Tie the knot with a double turn or square knot.
Move the ties so the restraints are secured to the side rails.
Ensure that the restraints are snug against the client's wrist.
285. Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse emphasize concerning the installation of the antipyrine/benzocaine otic solution?
Place the dropper on the upper outer ear canal and instill the medication slowly.
Warm the medication in the microwave for 10 seconds before instilling.
Keep the medication refrigerated between administrations.
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Have the child lie with the ear up for one to two minute after installation.
286. An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide?
Limit the intake of high calorie foods.
Eat meals at the same time daily.
Maintain a low protein diet.
Restrict daily fluid intake.
Rationale: the client is exhibiting signs of cor pulmonale, a complication of COPD that causes the right side of the heart to fail. Restricting fluid intake to 1000 to 2000 ml/day, eating a high-calorie diet at small frequent meals with foods that are high in protein and low in sodium can help relive the edema and decrease workload on the right-side of the heart.
287. The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next?
Remove the catheter and insert into urethral opening
Observe for urine flow and then inflate the balloon.
Insert the catheter further and observe for discomfort.
Leave the catheter in place and obtain a sterile catheter.
Rationale: the catheter is in the vaginal opening.
288. A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?
Prepare the skin for procedure.
Identify client's pulse points
Witness consent for procedure
Check telemetry monitoring
289. Fallowing an outbreak of measles involving 5 students in an elementary school, which action is most important for the school nurse to take?
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Review the immunization records of all children in the elementary school
Report the measles outbreak to all community health organizations
Schedule a mobile public health vehicle to offer measles inoculations to unvaccinated children.
Restrict unvaccinated children from attending school until measles outbreak is resolved.
290. A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement?
discontinue the magnesium sulfate immediately
Decrease the client's iv rate to 50 ml per hour
Continue with the plan of care for this client
Change the client's to NPO status
Rationale: continue with the plan. Diuresis in 24 to 48h after birth is a sign of improvement in the preeclamptic client. As relaxation of arteriolar spasms occurs, kidney perfusion increases. With improvement perfusion, fluid is drawn into the intravascular bed from the interstitial tissue and then cleared by the kidneys
291. The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts?
Express feelings of sadness and loneliness
Neglects personal hygiene and has no appetite
Lacks interest in the activity of the family and friends
Begin to show signs of improvement in affect
Rationale: when a depressed client begins to show signs of improvement, it can be because the client has "figured out" how to be successful in committing suicide. Depressed clients, particularly those who have shown signs of potentially becoming suicidal, should be watched with care for an impending suicide attempt might be greater when the client appear suddenly happy, begin to give away possessions, or becomes more relaxed and talkative.
292. When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first?
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Massage the uterus to decrease atony
Check for a destined bladder
Increase intravenous infusion
Review the hemoglobin to determined hemorrhage
Rationale: a fundus that is dextroverted (up to the right) and elevated above the umbilicus is indicative of bladder distension/urine retention.
293. A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement?
Evaluate postural blood pressure measurements
Obtain specimen for uranalysis
Encourage popsicles and fluids of choice
Assess bowel sounds in all quadrants
Rationale: specific gravity of urine is a measurement of hydration status (normal range of 1.010 to 1.025) which is indicative of fluid volume deficit when Sp Gr increases as urine becomes more concentrated.
294. An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement?
Obtain a urine specimen for culture and sensitivity
Palpate the client's suprapubic area for distention
Advise the client to maintain a voiding diary for one week
Instruct in effective technique to cleanse the glans penis
Rationale: the client is exhibiting classic signs of an enlarge prostate gland, which restricts urine flow and cause bothersome lower urinary tract symptoms (LUTS) and urinary retention, which is characterized by the client's voiding patterns and perception of incomplete bladder emptying.
295. The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old infant. Which action should the nurse include?
Select a 22 gauge 1 ½ inch (3.8 cm) needle for the intramuscular injection
Administer into the deltoid muscle while the parent holds the infant securely
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Divide the medication into two injection with volumes under 1ml
Use a quick dart-like motion to inject into the dorsogluteal site.
Rationale: IM injection for children under 3 of age should not exceed 1ml. divide the dose into smaller volumes for injection in two different sites.
296. A client who had a below the knee amputation is experiencing severe phantom limb pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful?
Research indicates that mirror therapy is effective in reducing phantom limb pain
You can try mirror therapy, but do not expect to complete elimination of the pain
Transcutaneous electrical nerve stimulators (TENS) have been found to be more effective
Where did you learn about the use of mirror therapy in treating in treating phantom limb pain?
Rationale: pain relief associated with mirror therapy may be due to the activation of neurons in the hemisphere of the brain that is contralateral to the amputated limb when visual input reduces the activity of systems that perceive protopathic pain.
297. An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?
Observe neck for jugular vein distention
Notify healthcare provider to prepare for pericardiocentesis
Asses for paradoxical blood pressure
Monitor oxygen saturation (Sp02) via continuous pulse oximetry
Rationale: Cardiac tamponade is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle (myocardium) and the outer covering sac of the heart (pericardium). In this condition, blood or fluid collects in the pericardium, the sac surrounding the heart. This prevents the heart ventricles from expanding fully. The excess pressure from the fluid prevents the heart from working properly. As a result, the body does not get enough blood.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 298. A new member joins the nursing team spreads books on the table, puts items on two chairs, and sits on a third chair. The members of the group are forced to move closer and remove their possessions from the table what action should the nurse leader take?
Move to welcome and accommodate a new person
Ask the new person to move belonging to accommodate others
Tell the new person to move belongings because of limited space
Bring in additional chairs so that all staff members can be seated
299. The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication?
Poor feeding and vomiting
Leakage of CSF from the incisional site
Hyperactive bowel sound
Abdominal distention
WBC count of 10000/mm3
300. The nurse is preparing a heparin bolus dose of 80 units/kg for a client who weighs 220 pounds. Heparin sodium injection, USP is available in a 3o ml multidose vial with the concentration of 1,000 USP units/ml. how many ml of heparin should the nurse administer? (Enter numeric value only)
8
Calculate the client’s weigh in kg: 220 pounds divides by 2.2 pounds/kg ꞊100 kg Calculate the client’s dose, 80 units x 100 kg ꞊ 8,000 units Use the formula, D / H X Q ꞊ 8,000 units / 1,000 units x 1ml ꞊ 8
301. In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should the nurse include in the plan of care?
Evaluate closet proximal pulse.
Asses skin elasticity of the stump.
Observe for swelling around the stump.
Note amount color of wound drainage.
Rationale: A primary focus of care for a client with an AKA is monitoring for signs of adequate tissue perfusion, which include evaluating skin color and ongoing assessment of pulse strength.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 302. The leg of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personal (UAP) place a heating pad on the mottled areas, what action should the nurse take?
Remove the heating pads and place a soft blanket over the client’s leg and feet.
Advise the UAP to observe the client’s skin while the heating pads are in place.
Elevate the client’s feet on a pillow and monitor the client’s pedal pulses frequently.
Instruct the UAP to reposition the heating pads to the sides of the legs and feet.
303. A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. What dietary instruction is most important for the nurse to explain to the client?
Chew food slowly and thoroughly before attempting to swallow
Plan volume-controlled evenly-space meal thorough the day
Sip fluid slowly with each meal and between meals
Eliminate or reduce intake fatty and gas forming food
Rationale: It is most important for the client to learn how to eat without damaging the surgical site and to keep the digestive system from dumping the food instead of digesting it. Eating volume-control and evenly-space meals thorough the day allows the client to fill full, avoid binging, and eliminate the possibility of eating too much one time. Chewing slowly and thoroughly helps prevent over eating by allowing a filling of fullness to occur. Taking sips, rather than large amounts of fluids keeps the stomach from overfilling and allow for adequate calories to be consumed. Gas forming foods and fatty foods should be avoiding to decrease risk of dumping syndrome and flatulence.
304. If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding?
The intravenous fluid replacement contains a hypertonic solution of sodium chloride
Urinary and Gastrointestinal fluid loss reduce blood viscosity and stimulate thirst
Insensible loss of body fluids contributes to the hemoconcentration of serum solutes
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Hypothalamic resetting of core body temperature causes vasodilation to reduce body heat
Rationale: Fever causes insensible fluid loss, which contribute to fluid volume and results in hemoconcentration of sodium (serum sodium greater than 150 mEq/L). Dehydration, which is manifested by dry, sticky mucous membranes, and flushed skin, is often managed by replacing lost fluids and electrolytes with IV fluids that contain varying concentration of sodium chloride. Although other options are consistent with fluid volume deficit, the physiologic response of hypernatremia is explained by hem concentration.
305. During a Woman’s Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN)
Encourage the woman at risk for cancer to obtain colonoscopy.
Present a class of breast-self examination
Prepare a woman for a bone density screening
Explain the follow-up need it for a client with prehypertension.
Rationale: A bone density screening is a fast, noninvasive screening test for osteoporosis that can be explained by the PN. There is no additional preparation needed (A) required a high level of communication skill to provide teaching and address the client’s fear. (B) Requires a higher level of client teaching skill than responding to one client. (D) Requires higher level of knowledge and expertise to provide needed teaching regarding this complex topic.
306. An adult client present to the clinic with large draining ulcers on both lower legs that are characteristics of Kaposi’s sarcoma lesions. The client is accompanied by two family member. Which action should the nurse take?
Ask family member to wear gloves when touching the patient
Send family to the waiting area while the client’s history is taking
Obtain a blood sample to determine is the client is HIV positive
Complete the head to toes assessment to identify other sign of HIV
Rationale: To protect the client privacy, the family member should be asked to wait outside while the client’s history is take. Gloves should be worn when touching the client’s body fluids if the client is HIV positive and these lesion are actually Kaposi sarcoma lesion. HIV testing cannot legally be done without the client explicit permission. A further assessment can be implemented after the family left the room.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 307. An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week ―I’m trying to start a new business and ―I’m too busy to eat‖. The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority?
Hygiene-self-care deficit
Imbalance nutrition
Disturbed sleep pattern
Self-neglect
Rationale: The client’s nutritional status has the highest priority at this time, and finger foods are often provided, so the client who is on the maniac phase of bipolar disease can receive adequate nutrition. Other options are nursing problems that should also be addresses with the client’s plan of care, but at this stage in the client’s treatment, adequate nutrition is a priority
308. The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan?
Limit intake fatty foods for one month after surgery.
Notify the healthcare provider if edema occurs.
Increase activity and exercise gradually, as tolerated.
Avoid crowds for first two months after surgery.
Rationale: Cyclosporine immunosuppression therapy is vital in the success of liver transplantation and can increase the risk for infection, which is critical in the first two months after surgery. Fever is often.
309. The nurse is assessing a client’s nailbeds. Witch appearance indicates further follow-up is needed for problems associated with chronic hypoxia?
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310. A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5pound weight gain. Which intervention the nurse implement?
Arrange transport for admission to the hospital.
Insert saline lock for IV diuretic therapy.
Assess compliance with routine prescriptions.
Instruct the client to monitor daily caloric intake.
Rationale: Fluid retention may be a sign that the client is not taking the medication as prescribed or that the prescriptions may need adjustment to manage cardiac function post-PTCA (normal ejection fraction range is 50 to 75%)
311. The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is
Two days postoperative bladder surgery with continuous bladder irrigation infusing.
One day postoperative laparoscopic cholecystectomy requesting pain medication.
Three days postoperative colon resection receiving transfusion of packed RBCs.
Preoperative, in buck’s traction, and scheduled for hip arthroplasty within the next 12 hours.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 312. The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be include in the discharge teaching?
Do not read without direct lighting for 6 weeks.
Avoid straining at stool, bending, or lifting heavy objects.
Irrigate conjunctiva with ophthalmic saline prior to installing antibiotic ointment.
Limit exposure to sunlight during the first 2 weeks when the cornea is healing.
Rationale: after cataract surgery, the client should avoid activities which increase pressure and place strain on the suture line.
313. The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled, ―10 mEq/5ml.‖ how many ml of potassium chloride should the nurse add the IV fluid? (Enter numeric value only. If is rounding is required, round to the nearest tenth.)
12.5
Rationale: Using the formula D / H X Q: 25 mEq / 10 mEq x 5ml ꞊12.5ml
314. At 40 week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take?
Encourage the client to turn on her left side.
Place a pillow under the client’s head and knees.
Explain to the client that her position is not safe.
Place a wedge under the client’s right hip.
Rationale: Hypotension from pressure on the vena cava is a risk for the full-term client. Placing a wedge under the right hip will relieve pressure on the vena cava. Other options will either not relieve pressure on the vena cava or would not allow the client the remaining her position of choice.
315. A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client’s blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client’s average urinary output is 5 ml/hour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump. With intervention should the nurse implement?
Irrigate the indwelling urinary catheter.
Prepare the client for external pacing.
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Obtain capillary blood glucose measurement.
Titrate the dopamine infusion to raise the BP.
Rationale: the client is experiencing cardiogenic shock and requires titration per protocol of the vasoactive secondary infusion, dopamine, to increase the blood pressure. Low hourly urine output is due to shock and does not indicate a need for catheter irrigation. Pacing is not indicated based on the client’s capillary blood glucose should be monitored, but is not directly indicated at this time.
316. The nurse ends the assessment of a client by performing a mental status exam. Which statement correctly describes the purpose of the mental status exam?
Determine the client’s level of emotional functioning’
Assess functional ability of the primary support system.
Evaluate the client’s mood, cognition and orientation.
Review the client’s pattern of adaptive coping skill
Rational: the mental status exam assesses the client for abnormalities in cognitive functioning; potential thought processes, mood and reasoning, the other options listed are all components of the client’s psychosocial assessment.
317. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client’s blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply)
Administer a daily dose of lisinopril as scheduled.
Assess the client for postural hypotension.
Notify the healthcare provider immediately
Provide a PRN dose of acetaminophen for headache
Withhold the next scheduled daily dose of warfarin.
Rational: the client’ routinely scheduled medication, lisinopril, is an antihypertensive medication and should be administered as scheduled to maintain the client’s blood pressure. A PRN dose of acetaminophen should be given for the client’s headache. The other options are not indicated for this situation.
318. When conducting diet teaching for a client who is on a postoperative soft diet, which foods should eat? (Select all that apply)
Pasta, noodles, rice.
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Egg, tofu, ground meat.
Mashed, potatoes, pudding, milk.
Brussel sprouts, blackberries, seeds.
Corn bran, whole wheat bread, whole grains.
Rational: a client’s postoperative diet is commonly progressed as tolerated. A soft diet includes foods that are mechanically soft in texture (pasta, egg, ground meat, potatoes, and pudding. High fiber foods that require thorough chewing and gas forming foods, such as cruciferous vegetables and fresh fruits with skin, grains and seeds are omitted.
319. The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan?
Reposition the infant every 2 hours.
Perform diaper changes under the light.
Feed the infant every 4 hours.
Cover with a receiving blanket.
Rational: An infant, who is receiving phototherapy for hyperbilirubinemia, should be repositioned every two hours. The position changes ensure that the phototherapy lights reach all of the body surface areas. Bathing, feedings, and diaper changes are ways for the parents to bond with the infant, and can occur away from the treatment. Feedings need to occur more frequently than every 4 hours to prevent dehydration. The infant should wear only a diaper so that the skin is exposed to the phototherapy.
320. When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority?
Withhold food and fluid intake.
Initiate IV fluid replacement.
Administer antiemetic as needed.
Evaluate intake and output ratio.
Rational: The pathophysiologic processes in acute pancreatitis result from oral fluid and ingestion that causes secretion of pancreatic enzymes, which destroy ductal tissue and pancreatic cells, resulting in auto digestion and fibrosis of the pancreas. The main focus of the nursing care is reducing pain caused by
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) pancreatic destruction through interventions that decrease GI activity, such as keeping the client NPO. Other choices are also important intervention but are secondary to pain management. 321. Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipations. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client’s constipation, which suggestions should the nurse provide? (Select all that apply)
Decrease laxative use to every other day, and use oil retention enemas as needed.
Include oatmeal with stewed pruned for breakfast as often as possible.
Increase fluid intake by keeping water glass next to recliner.
Recommend seeking help with regular shopping and meal preparation.
Report constipation to healthcare provider related to cardiac medication side effects.
Rational: older adult are at higher risk for chronic constipation due to decreased gastrointestinal muscle tone leading to reduce motility. Oatmeal with prunes increases dietary fiber and bowel stimulation, thereby decreasing need for laxatives. Increased fluid intake also decreases constipations. Assistance with food preparation might help the client eat more fresh fruits and vegetables and result on less reliance on microwaved and fast foods, which are usually high in sodium and fat with little fiber. Laxatives can be reduced gradually by improving the diet, without resorting to using enemas.
322. A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and which action should the nurse implement next?
Report the incident to the local child protective services.
Find a home health agency that specializes in brain injuries.
Determine the mother’s basic skill level in providing care.
Consult the ethics committee to determine how to proceed.
Rational: Although the mother states she is a capable caregiver, the client is manifesting disuse syndrome complications, and the mother’s skill in providing basic care should be determined. Further assessment is needed before implementing other nursing actions.
323. After the risk and benefits of having a cardiac catheterization are reviewed by the healthcare provider, an older adult with unstable angina is scheduled for the procedure.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) When the nurse presents the consent form for signature, the client asks how the wires will keep a heart heating during the procedure. What action should the nurse take?
Explain the procedure again in detail and clarify any misconceptions.
Notify the healthcare provider of the client’s lack of understanding.
Call the client’s next of kin and have them provide verbal consent.
Postpone the procedure until the client understands the risk and benefits.
Rational: the nurse is only witnessing the signature, and is not responsible for the client’s understanding of the procedure. The healthcare provider needs to clarify any questions and misconceptions. Explaining the procedure again is the healthcare provider’s legal responsibility. The other options are not indicated.
324. In assessing a client at 34-weeks’ gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28%, a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up?
Elevated thyroid hormone level.
Hematocrit of 28%.
Heart rate of 92 beats per minute.
Systolic murmur.
Rational: although physiologic anemia is expected in pregnancy, a hematocrit of 28% is below pregnant norms and could signify iron-deficiency anemia. Other options are normal finding pregnancy
325. A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client’s serum laboratory values requires intervention by the nurse?
Total calcium 9 mg/dl (2.25 mmol/L SI)
Creatinine 4 mg/dl (354 micromol/L SI)
Phosphate 4 mg/dl (1.293 mmol/L SI)
Fasting glucose 95 mg/dl (5.3 mmol/L SI)
326. A clinical trial is recommended for a client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client’s son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond?
Ask the client with her children present if she fully understands the decision she has made.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Discuss success of clinical trials and ask the client to consider participating for one month.
Explain to the family that they must accept their mother’s decision.
Explore the client’s decision to refuse treatment and offer support
Rationale: as long as the client is alert, oriented and aware of the disease prognosis, the healthcare team must abide by her decisions. Exploring the decision with the client and offering support provides a therapeutic interaction and allows the client to express her fears and concerns about her quality of life. Other options are essentially arguing with the client’s decisions regarding her end of life treatment or diminish the opportunity for the client to discuss her feelings
327. An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran one year ago, his spouse states that the client no longer runs, bur sits and watches television most of the day. Which is most important for the nurse to include in this client’s plan of care for today?
Assist client in identifying goals for the day.
Encourage client to participate for one hour in a team sport.
Schedule client for a group that focuses on self-esteem.
Help client to develop a list of daily affirmations.
Rationale: clients with severe depression have low energy and benefit from structured activities because concentration is decreased. The client participate in care by identifying goals for the day is the most important intervention for the client’s first day at the unit. Other options can be implemented over time, as the depression decreases.
328. An adult who is 5 feet 5 inches (165.1 cm) tall and weighs 90 lb. (40.8 Kg) is admitted with a diagnosis of chronic anorexia. The client receives a regular diet for 2 days, and the client’s medical records indicates that 100% of the diet provided has been consumed. However the client’s weight on the third day morning after admission is 89 lb. (40.4 Kg). What action should the nurse implement?
Examine the client’s room for hidden food.
Assign staff to monitor what the client eats.
Ask the client if the food provided is being eaten or discarded.
Provide the client with a high calorie diet.
Rationale: clients with an eating disorder have an unhealthy obsession with food. The client’s continued weight loss, despites indication that the client has
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) consumed 100% of the diet, should raise questions about the client’s intake of the food provided, so the client should be observed during meals to prevent hiding or throwing away food. Other options may be accurate but ineffective and unnecessary. 329. A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?
Conversion of the client’s PPD test from negative to positive.
Length of time of the exposure to tuberculosis.
Current diagnosis of hepatitis B.
History of intravenous drug abuse.
Rationale: prophylactic treatment of tuberculosis with isoniazid is contraindicated for persons with liver disease because it may cause liver damage. The nurse should withhold the prescribed dose and contact the healthcare provider. Other options do not provide data indicating the need to question or withhold the prescribed treatment.
330. The nurse walks into a client’s room and notices bright red blood on the sheets and on the floor by the IV pole. Which action should the nurse take first?
Clean up the spilled blood to reduce infection transmission.
Notify the healthcare provider that the client appears to be bleeding.
Apply direct pressure to the client’s IV site.
Identify the source and amount of bleeding.
Rationale: the nursed should first assess the client to determine the action that should be taken. Patient safety is the priority; other options are not priority.
331. During a routine clinic visit, an older female adult tells the nurse that she is concerned that the flu season is coming soon, but is reluctant to obtain the vaccination. What action should the nurse take first?
Determine when the client last had an influenza vaccination.
Discuss the concerns expressed by the client about the vaccination.
Ask about any recent exposure to persons with the flu or other viruses.
Review the informed consent form for the vaccination with the client.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Rationale: the nurse should first address the concerns identified by the client, before taking other actions, such as obtaining information about past vaccinations, exposure to the flu, or reviewing the informed consent form.
332. A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs q2 hours. Which finding should the nurse report immediately to the healthcare provider?
Confusion and tremors
Yellowing and itching of skin.
Abdominal pain and vomiting
Anorexia and abdominal distention
Rationale: daily alcohol is the likely etiology for the client’s pancreatitis. Abrupt cessation of alcohol can result in delirium tremens (DT) causing confusion and tremors, which can precipitate cardiovascular complications and should be reported immediately to avoid life-threatening complications. The other options are expected findings in those with liver dysfunction or pancreatitis, but do not require immediate action.
333. The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using medela haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple’s elongated tip in the back of the oral cavity. What instructions should the nurse provide the mother about feedings?
Squeeze the nipple base to introduce milk into the mouth
Position the baby in the left lateral position after feeding
Alternate milk with water during feeding
Hold the newborn in an upright position
Rationale: the mother should be instructed to hold the infant during feedings in a sitting or upright position to prevent aspiration. Impaired sucking is compensated by the use of special feeding appliances and nipples such as the haberman feeder that prevents aspiration by adjusting the flow of mild according to the effort of the neonate. Squeezing the nipple base may introduce a volume that is greater than the neonate can coordinate swallowing. The preferred positon of an infant after feeding is on the right side to facilitate stomach emptying. Sucking difficulty impedes the neonate’s intake of adequate nutrient needed for weight gain and water should be provided after the feeding to cleanse the oral cavity and not fill up the neonate’s stomach.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 334. Following and gunshot wound, an adult client a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is not type AB negative blood currently available. Which intervention should the nurse implement?
Transfuse Type A negative blood until type AB negative is available.
Recheck the client’s hemoglobin, blood type and Rh factor.
Administer normal saline solution until type AB negative is available
Obtain additional consent for administration of type A negative blood
Rationale: those who have type AB blood are considered universal recipients using A or B blood types that is the same Rh factor. The client’s hemoglobin is critically low and the client should receive a unit of blood that is type A, which must be Rh negative blood. Other options are not indicated in this situation.
335. A young adult female college student visits the health clinic in early winter to obtain birth control pills. The clinic nurse asks if the student has received an influenza vaccination. The student stated she did not receive vaccination because she has asthma. How should the nurse respond?
Offer to provide the influenza vaccination to the student while she is at the clinic
Encourage the student to obtain a vaccination prior to the next influenza season.
Confirm that a history of asthma can increase risks associated with the vaccine.
Advise the student that the nasal spray vaccine reduces side effects for people with asthma.
Rationale: person with asthma are at increased risk related to influenza and should receive the influenza vaccination prior to or during influenza season. Waiting until the start of the next season places the student at risk for the current season. The vaccination does not increase risk for persons with asthma but the nasal spray may result in increased wheezing after receiving that form of the vaccination.
336. A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply)
Topical corticosteroid.
Topical scabicide.
Topical alcohol rub.
Transdermal analgesic.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Oral antihistamine
Rationale: anti-inflammatory actions of topical corticosteroids and oral antihistamines provide relief from severe pruritus (itching). Other options are not indicated.
337. The nurse is using a straight urinary catheter kit to collect a sterile urine specimen from a female client. After positioning am prepping this client, rank the actions in the sequence they should be implemented. (Place to first action on the top on the last action on the bottom.)
Correct : ODCP
1. Open the sterile catheter kit close to the client’s perineum.
2. Don sterile gloves and prepare to sterile field
3. Cleanse the urinary meatus using the solution, swabs, and forceps provided
4. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus
Rationale: First the kit should be open near the clients to minimize the risk of contamination during the collection of the sterile specimen. Once the kit is opened, sterile gloves should be donned to prepare the sterile field. Then the clients’ meatus should be cleansed, and the catheter inserted while to distal end of the catheter drains urine into the sterile specimen cup or receptacle.
338. An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. What is the best response by the nurse?
Explain that the client will start to lose consciousness and his body system will slow down
Reassure the spouse that the healthcare provider will let her know when to call the children
Offer to discuss the client’s health status with each of the adult children
Gather information regarding how long it will take for the children to arrive
Rationale: Expected signs of approaching death include noticeable changes in the client’s level of consciousness and a slowing down of body systems. The nurse should answer the spouse’s questions about the signs of imminent death rather than offering reassurance that may or may not be true. Other options listed may be implemented but the nurse should first answer the spouse’s question directly.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 339.
When should intimate partner violence (IPV) screening occur?
As soon as the clinician suspects a problem
Only when a client presents with an unexplained injury
As a routine part of each healthcare encounter
Once the clinician confirms a history of abuse
Rationale: Universal screening for IPV is a vital means to identify victims of abuse in relationship. The suspicious of different clinicians vary greatly, so screening would not be implemented consistently. The client should be screened regardless of the presence of injury. Although history of abuse is difficult to confirm, screening should occur regardless, and this incident may know may be initial case of abuse.
340. A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?
Instructions about how much fluid the child should drink daily
information about non-pharmaceutical pain reliever measures
Referral for social services for the child and family
Signs of addiction to opioid and medications
Rationale: It is essential that the child and family understands the importance of adequate hydration in preventing the stasis-thrombosis-ischemia cycle of a crisis that has a specific plan for hydration is developed so that a crisis can be delayed. Other choices listed are not the most important topics to include in the discharge teaching.
341. What action should the school nurse implement to provide secondary prevention to a school-age children?
Collaborate with a science teacher to prepare a health lesson
Prepare a presentation on how to prevent the spread of lice
Initiate a hearing and vision screening program for first-graders
Observe a person with type 1 diabetes self-administer a dose of insulin
Rationale: Community care occurs at primary, secondary, and tertiary levels of prevention. Primary prevention involves interventions to reduce the incidence of disease. Secondary prevention includes screening programs to detect disease. Tertiary prevention provides treatment directed toward clinically apparent
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) disease. Secondary prevention focuses on screaming children for a specific disease processes such as hearing and vision screening. The other options are not examples of secondary prevention. 342. While assisting a client who recently had a hip replacement into a bed pan, the nurse notices that there is a small amount of bloody drainage on the surgical dressing, the client’s skin is warm to the touch, and there is a strong odor from the urine. Which action should the nurse take?
Obtain a urine sample from the bed pan
Remove dressing and assess surgical site
Insert an indwelling urinary catheter
Measure the client’s oral temperature
Rationale: The strong odor from the urine and skin that is warm to the touch may indicate that the client has a urinary tract infection. Assessing the client’s temperature provides objective information regarding infection that can be reported to the healthcare provider. Urine should be obtained via a clean catch, not the bed pan where it has been contaminated. The drainage on the dressing is normal and does not require direct conservation at this time. An indwelling catheter should be avoided if possible because it increases the risk of infection.
343. While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side-table. The client is currently receiving at 2 litters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement?
Assist the client to lie back in bed
Call for an Ambu resuscitating bag
Increase oxygen to 6 litters/minute
Administer a nebulizer Treatment
Rationale: The client needs an immediate medicated nebulizer treatment. Sitting in an upright position with head and arms resting on the over-bed table is an ideal position to promote breathing because it promotes lung expansion. Other actions me be accurate but not yet indicated.
344. A client with emphysema is being discharged from the hospital. The nurse enters the client’s room to complete discharge teaching. The client reports feeling a little short of breath and is anxious about going home. What is the best course of action?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Postpone discharge instructions at this time and offer to contact the client by phone in a few days
Invite the client to return to the unit for discharge teaching in a few days, when there is less anxiety
Provide only necessary information in short, simple explanations with written instructions to take home
Give detailed instructions speaking slowly and clearly while looking directly at the client when speaking
Rationale: Simple, short explanations should be provided. Information is not retained when the recipient is anxious, and too much information can increase worry. Ethically, discharge instructions may not be postponed.
345. An older adult male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours. He is found wandering into another client’s room and is return to his room by the unlicensed assistive personnel (UAP). What actions should the nurse take? (Select all that apply).
Apply soft upper limb restrains and raise all four bed rails
Report mental status change to the healthcare provider
Assess the client’s breath sounds and oxygen saturation
Assign the UAP to re-assess the client’s risk for falls
Review the client’s most recent serum electrolyte values
Rationale: The healthcare provider should be informed of changes in the client’s condition (B) because this behavior may indicate a postoperative complication. Diminished oxygenation (C) and electrolyte imbalance (E) may cause increased confusion in the older adult. Raising all four bed rails (A) may lead to further injury if the client climbs over the rails and falls and restrains should not be applied until other measures such as re-orientation are implemented. The nurse should assess the client’s increased risk for falls, rather than assigning this to the UAP (D).
346. A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administered to prevent the development of Wernicke's syndrome?
Lorazepam (Ativan)
Famotidine (Pepcid)
Thiamine (Vitamin B1)
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Atenolol (Tenormin)
Rationale: Thiamine replacement is critical in preventing the onset of Wernickes encephalopathy, an acute triad of confusion, ataxia, and abnormal extraocular movements, such as nystagmus related to excessive alcohol abuse. Other medications are not indicated.
347. When conducting diet teaching for a client who was diagnosed with nutritional anemia in pregnancy, which foods should the nurse encourage the client to eat? (Select all that apply)
Seeds, spices, lettuce
Consomme, celery, carrot
Oranges, orange juice, bananas
Fortified whole wheat cereals, whole-grain pasta, brown rice
Spinach, kale, dried raisins and apricots
Rationale: Nutritional anemia in pregnancy should be supplemented with additional iron in the diet. Foods that are high in iron content are often protein based, whole grains (D), green leafy vegetables and dried fruits (E). (A, B, and C) are not iron rich sources
348. A client with type 2 diabetes mellitus is admitted for antibiotic treatment for a leg ulcer. To monitor the client for the onset of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), what actions should the nurse take? (Select all that apply)
Check urine for ketones
Measure blood glucose
Monitor vital signs
Assessed level of consciousness
Obtain culture of wound
Rationale: Blood glucose greater than 600 mg/dl (33.3 mmol/L SI), vital sign changes in mental awareness are indicators of possible HHNS. Urine ketones are monitored in diabetic ketoacidosis. Wound culture is performed prior to treating the wound infection but is not useful in monitoring for HHNS.
349. An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth)
0.4
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Rationale: Calsulate using the formula, desired dose (220,000 units) over dose on hand (600,000 units) x the volume of the available dose (1 ml). 220,000 / 600,000 x 1 ml = 0.36 = 0.4 ml
350. After receiving report, the nurse can most safely plan to assess which client last? The client with…
A rectal tube draining clear, pale red liquid drainage
A distended abdomen and no drainage from the nasogastric tube
No postoperative drainage in the Jackson-Pratt drain with the bulb compressed
Dark red drainage on a postoperative dressing, but no drainage in the Hemovac®.
Rationale: The most stable client is the one with a functioning drainage device and no drainage. This client can most safely be assesses last. Other clients are either actively bleeding, have an obstruction in the nasogastric tube which may result in vomiting, or may be bleeding and / or may have a malfunction in the Hemovac® drain.
351. The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned?
Empty the urinary drainage bag
Feed the client a snack
Offer the client oral fluids
Assess the breath sounds
Rationale: Increasing oral fluid intake reduces the risk of problems associated with immobility, so the UAP should be instructed to offer the client oral fluids every two hours, or whenever turning he client. It is not necessary to empty the urinary bag or feed the client every two hours. Assessment is a nursing function, and UAPs do not have the expertise to perform assessment of breath sounds.
352. The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply)
Inspect skin for redness
Use a residual limb shrinker
Apply alcohol to the stump after bathing
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Wash the stump with soap and water
Avoid range of motion exercises
Rationale: Several actions are recommended for home care following an amputation. The skin should be inspected regularly for abnormalities such as redness, blistering, or abrasions. A residual limb shrinker should be applied over the stump to protect it and reduce edema. The stump should be washed daily with a mild soap and carefully rinse and dried. The client should avoid cleansing with alcohol because it can dry and crack the skin. Range of motion should be done daily.
353. When assessing the surgical dressing of a client who had abdominal surgery the previous day, the nurse observes that a small amount of drainage is present on the dressing and the wound’s Hemovac suction device is empty with the plug open. How should the nurse respond?
Replace the dressing and remove the drainage device
Reposition the drainage device and keep the plug open
Notify the healthcare provider that the drain is not working
Recompress the wound suction device and secure to plug
Rationale: The plug of a wound suction device, such as a Hemovac, should be closed after compressing the device to apply gentle suction in a closed surgical wound to facilitate the evacuation of subcutaneous fluids into the device. Compressing the device and securing the plug should restore function of the closed wound device. A small amount of drainage should be marked on the dressing, but replacing the dressing is not necessary and the nurse should not remove the device. Other options are not indicated.
354. A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child’s hernia. Which explanations should the nurse provide?
This hernia is a normal variation that resolves without treatment.
Restrictive clothing will be adequate to help the hernia go away.
An abdominal binder can be worn daily to reduce the protrusion.
The quarter should be secured with an elastic bandage wrap.
Rational: an umbilical hernia is a normal variation in infants that occurs due to an incomplete fusion of the abdominal musculature through the umbilical ring that usually resolves spontaneously as the child learns to walk. Other choices are ineffective and unnecessary.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 355. A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?
Patch one eye.
Reorient often.
Range of motion.
Evaluate swallow
Rational: Osmotic demyelination, also known as central pontine myelinolysis, is nerve damage caused by the destruction of the myelin sheath covering nerve cells in the brainstem. The most common cause is a rapid, drastic change in sodium levels when a client is being treated for hyponatremia, a common occurrence in SIADH. Difficulty swallowing due to brainstem nerve damage should be care, but determining the client’s risk for aspiration is most important.
356. A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement?
Collect a clean catch urine specimen.
Instruct the client to empty the bladder.
Obtain vital signs and breath sounds.
No specific nursing action is required
Rational: the client’s baseline cardiovascular status should be determined before conducting the fluid challenge. If the client manifests changes in the vital signs and breath sounds associated with pulmonary edema, the administration of the fluid challenge should be terminate. Other options would not assure a safe administration of the medication.
357. A male client with COPD smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly?
―I have a hard time inhaling and holding my breath after I squeeze the inhaler, but I do my best‖
― I never use the inhaler unless I am feeling really short of breath‖
I always shake the inhaler several times before I start‖
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
“After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, bit it goes away”
358. A nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. What information is most important for the nurse to include?
Ensure that the infant’s crib mattress is firm
359. A 6 -years-old who has asthma is demonstrating a prolonged expiratory phase and wheezing, and has 35% personal best peak expiratory flow rate (PEFR). Based on these finding, which action should the nurse implement first?
Administer a prescribed bronchodilator.
Report finding to the healthcare provider.
Encourage the child to cough and deep breath
Determine what trigger precipitated this attack.
Rationale: If the PEFR is below 50% in as asthmatic child, there is severe narrowing of the airway, and a bronchodilator should be administered immediately. Be should be implemented after A. C will not alleviate the symptoms and D is not a priority.
360. A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the client’s therapeutic response to this medication, which assessment should the nurse obtain?
Level of consciousness
Percussion of abdomen
Serum electrolytes
Blood glucose.
Rationale: Colonic bacteria digest lactulose to create a drug-induces acidic and hyperosmotic environment that draws water and blood ammonia into the colon and coverts ammonia to ammonium, which is trapped in the intestines and cannot be reabsorbed into the systemic circulation. This therapeutic action of lactulose is to reduce serum ammonia levels, which improves the client’s level of consciousness and metal status.
361. When administering an immunization in an adult client, the nurse palpates and administer the injection one inch below the acromion process into the center of the muscle mass. The nurse should document that the vaccine was administered at what site?
Rectus femenis
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Ventrogluteous
Vastus lateralis
Deltoid
Rationale: The acromion process is a parameter identified for the deltoid site.
362. A primigravida a 40-weeks gestation with preeclampsia is admitted after having a seizure in the hot tub at a midwife’s birthing center. Based on documentation in the medical record, which action should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.)
Continue to monitor the client’s blood pressure hourly
363. A female nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the nurse has asked administration to allow her to return to work. When the nurse administrator approaches the charge nurse with the impaired nurse request, which action is best for the charge nurse to take?
Since treatment is completed, assign the nurse to the route RN responsibilities
Ask to meet with impaired nurse’s therapist before allowing her back on the unit.
Allow the impaired nurse to return to work and monitor medication administration
Meet with staff to assess their feelings about the impaired nurse’s return to the unit.
Rationale: provides essential monitoring and helps ensure nurse compliance and promote client safety.
364. In making client care assignment, which client is best to assign to the practical nurse (PN) working on the unit with the nurse?
An immobile client receiving low molecular weight heparin q12 h.
A client who is receiving a continuous infusion of heparin and gets out of bed BID
A client who is being titrated off heparin infusion and started on PO warfarin (Coumadin)
An ambulatory client receiving warfarin (Coumadin) with INR of 5 second.
Rationale: A describe the most stable client. The other ones are at high risk for bleeding problems and require the assessment skills.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 365. A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complain of difficulty breathing. The nurse determine the client is tachypneic with absent breath sounds in the client’s right lungs fields. Which additional finding indicates that the client has developed a tension pneumothorax?
Continuous bubbling in the water seal chamber
Decrease bright red blood drainage
Tachypnea and difficulty breathing
Tracheal deviation toward the left lung.
Rationale: Tracheal deviation toward the unaffected left lung with absent breath sounds over the affected right lung are classic late signs of a tension pneumothorax.
366. A low-risk primigravida at 28-weeks gestation arrives for her regular antepartal clinic visit. Which assessment finding should the nurse consider within normal limits for this client?
Pulse increase of 10 beats/minute
Proteinuria
Glucosuria
Fundal height 0f 22 centimeters
367. The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client’s medical history?
Frequency of laxative use for chronic constipation
368. Which action should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom)
Correct order: (PADD) 1. Place stethoscope in suprasternal area to auscultate for bronchial sounds 2. Auscultate bronchovesicular sounds from side to side the first and second intercostal spaces 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 4. Document normal breath sounds and location of adventitious breath sounds 369. A client with chronic alcoholism is admitted with a decreased serum magnesium level. Which snack option should the nurse recommend to this client?
Cheddar cheese and crackers.
Carrot and celery sticks.
Beef bologna sausage slices.
Dry roasted almonds.
Rational: alcoholism promotes inadequate food intake and gastrointestinal loss of magnesium include green leafy vegetables and nuts and seeds. Other snacks listed provide much lower amounts of magnesium per serving.
370. The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. What expected outcome has the highest priority for this client?
Identifies 2 treatments for constipation due to immobility.
Names 3 home safety hazards to be resolve immediately.
State 4 risk factors for the development of osteoporosis.
Lists 5 calcium-rich foods to be added to her daily diet.
Rational: a major teaching goal for an elderly client with osteoporosis is maintenance of safety to prevent falls. Injury due to a fall, usually resulting in a hip fracture, can result in reduced mobility and associated complications. Other goals are also important when teaching clients who have osteoporosis, but they do not have the priority of preventing falls, which relates to safety.
371. The nurse is teaching a male adolescent recently diagnosed with type 1diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate do you effectiveness of the teaching?
Ask the adolescent to describe his level of comfort with injecting himself with insulin.
Observe him as he demonstrates self-injection technique in another diabetic adolescent
Have the adolescent list the procedural steps for safe insulin administration.
Review his glycosylated hemoglobin level 3 months after the teaching session.
Rational: watching the adolescent perform the procedure with another adolescent provides peer support the most information regarding his skill with self-injection.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) Other options do not provide information about the effectiveness of nurse’s teaching. 372. A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond?
Explain that counseling will be provided to give her information about her cancer risk
Gather additional information about the client’s family history for all types of cancer.
Offer assurance that there are a variety of effective treatments for breast cancer.
Provide information about survival rates for women who have this genetic mutation.
Rational: BRACA1or BRACA2 genetic mutation indicates an increased risk for developing breast or ovarian cancer and genetic counseling should be provided to explain the increased risk (A)to the client along with options for increased screening or preventative measures. (B) Is completed by the genetic counselor before the client undergoes genetic testing. a positive BRACA1test is not an indicator of the presence of cancer and (C and D) are not appropriate responses prior to genetic counseling.
373. A mother runs into the emergency department with s toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first?
Call poison control emergency number.
Determine type of chemical exposure.
Obtain equipment for gastric lavage.
Assess child for altered sensorium.
Rational: once the type of chemical is determined, poison control should be called even if the chemical is unknown. If lavage is recommended by poison control, intubation and nasogastric tube may be needed as directed by poison control. Altered sensorium, such as lethargy, may occur if hydrocarbons are ingested
374. The nurse assigned unlicensed assistive personnel (UAP) to apply antiembolism stockings to a client. The nurse and UAP enters the room, the nurse observes the stockings that were applying by the UAP. The UAP states that the client requested application of the stockings as seen on the picture, for increased comfort. What action should the nurse take?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Ask the client if the stocking feel comfortable.
Supervise the UAP in the removal of the stockings.
Place a cover over the client’s toes to keep them warm.
Discussed effective use of the stockings with the client on UAP
Rational: antiembolism stockings are designed to fit securely and should be applied so that there are no bands of the fabric constricting venous return. The nurse should discuss the need for correct and effective use of the stockings with both the client and UAP to improve compliance. Other options do not correct the incorrect application of the stockings.
375. Nurses working on a surgical unit are concerned about the physicians treatment of clients during invasive procedures, such as dressing changes and insertion of IV lines. Clients are often crying during the procedures, and the physician is usually unconcerned or annoyed by the client’s response. To resolve this problem, what actions should the nurses take? (Arrange from the first action on the top of the list on the bottom) 1. Talk to the physician as a group in a non-confrontational manner. 2. Document concerns and report them to the charge nurse. 3. Submit a written report to the director of nursing. 4. Contact the hospital’s chief of medical services. 5. File a formal complaint with the state medical board.
Rational: nurses have both an ethical and legal responsibility to advocate for clients’ physical and emotional safety. Talking with the physician in a nonconfrontational manner is the first step in conflict resolution. If this is not effective, the organizational chain of ineffective, a formal complaint with the state medical board should be implemented.
376. While changing a client’s chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take?
Apply a pressure dressing around the chest tube insertion site.
Assess the client for allergies to topical cleaning agents.
Measure the area of swelling and crackling.
Administer an oral antihistamine per PRN protocol.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Rational: a crackling sensation, or crepitus, indicates subcutaneous emphysema, or air leaking into the skin. This area should be measured and the finding documented. Other options are not indicated for crepitus.
377. To prevent infection by auto contamination during the acute phase of recovery from multiple burns, which intervention is most important for the nurse to implement?
Dress each wound separately.
Avoid sharing equipment between multiple clients.
Use gown, mask and gloves with dressing change.
Implement protective isolation.
Rational: each wound should be dressed separately using a new pair of sterile glove to avoid auto contamination (the transfer of microorganisms form one infected wound to a non-infected wound). The other choices do not prevent auto contamination.
378. The nurse is preparing an intravenous (IV) fluid infusion using an IV pump. Within 30 seconds of turning on the machine, the pump’s alarm beeps ―occlusion‖. What action should the nurse implement first?
Flush the vein with 3 ml of sterile normal saline.
Assess the IV catheter insertion site for infiltration.
Verify the threading of the tubing through the IV pump.
Determine if the clamp on the IV tubing is released
Rational: When the pump immediately beeps, it is often because the IV tubing clamp is occluding the flow, so the clamp should be checked first to ensure that it is open. If the alarm is not eliminated after the tubing clamp is released, flushing the IV site with saline is a common practice to clean the needle or to identify resistance due to another source. Local signs of infiltration may indicate the need to select another vein, but the pump’s beeping-this early in the procedure is likely due to a mechanical problem. If beeping continues after verifying that the clamp is released the placement or threading of the tubing through the pump should be verified.
379. A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?
Sed rate (ESR)
Hemoglobin
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Calcium
Osmolality.
Rational: naproxen can cause gastric bleeding, so the nurse should monitor the client’s hemoglobin to assess for possible bleeding. Other options are not likely to be affected by the used of naproxen and are not related to the client’s current symptoms.
The nurse assesses a child in 90-90 traction. Where should did nurse assess for signs of compartment syndrome?
380.
Rationale: compartment syndrome is the result of swelling and subsequent reduction in circulation to the area distal to the compartment. This can be a complication of traumatic injury and cast administration, so it is important to assess circulation distal to the casted prolonged capillary refill.
381. After receiving the Braden scale findings of residents at a long-term facility, the charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize the skin care for which client?
An older adult who is unable to communicate elimination needs.
An older man whose sheets are damped each time he is turned.
A woman with osteoporosis who is unable to bear weight.
A poorly nourished client who requires liquid supplement.
Rational: a Braden score of less than 18 indicates a risk for skin breakdown, and clients with such score require intensive nursing care. Constant moisture places the client at a high risk for skin breakdown, and interventions should be
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) implemented to pull moisture away from the client’s skin. Other options may be risk factors but do not have as high a risk as constant exposure to moisture. 382. A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes Mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client’s plan of care?
Monitor the client’s cardiac activity via telemetry.
Maintain venous access with an infusion of normal saline.
Assess glucose via fingerstick q4 to 6 hours.
Evaluate hourly urine output for return of normal renal function.
Rational: as insulin lowers the blood glucose of a client with diabetic ketoacidosis (DKA), potassium returns to the cell but may not impact hyperkalemia related to acute renal failure. The priority is to monitor the client for cardiac dysrhythmias related to abnormal serum potassium levels. IV access, assessment of glucose level, and monitoring urine output are important interventions, but do not have the priority of monitoring cardiac function.
383. A client with C-6 spinal cord injury rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or ―goosebumps‖. The nurse should asses for which trigger?
Loud hallway noise.
Fever
Full bladder
Frequent cough.
Rational: a pounding headache is a sign of autonomic hyperreflexia, an acute emergency that occurs because of an exaggerated sympathetic response in a client with a high level spinal cord injury. Any stimulus below the level of injury can trigger autonomic hyperreflexia, but the most common cause is an overly distended bladder. The other options are unlikely to produce the manifestation of autonomic hyperreflexia.
384.
A nurse working on an endocrine unit should see which client first?
An adolescent male with diabetes who is arguing about his insulin dose.
An older client with Addison’s disease whose current blood sugar level is 62mg/dl (3.44 mmol/l).
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350 ml in the last hour.
A client taking corticosteroids who has become disoriented in the last two hours.
Rational: meeting the client’s need for safety is a priority intervention. Mania and psychosis can occur during corticosteroids therapy, places the client at risk for injury, so the patient taking corticosteroids should be seen first.
385. A client is receiving and oral antibiotic suspension labeled 250 mg/2ml. The healthcare provider prescribes 200mg every 6 hours. How many ml should the nurse administer at each dose? (Enter numerical value only. If rounding is required, round to the nearest tenth)
Answer: 1.6
Rational: using the formula D/H x Q
200mg/250 mg x 2ml = 200/250 = 1.6 ml
386. Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. What action should the nurse take?
Reposition the transdermal patch to the client’s trunk.
Remove the transdermal patch until the vomiting subsides.
Notify the healthcare provider of the vomiting.
Explain that this is a side effect of the medication in the patch.
Rational: transdermal scopolamine is used to prevent nausea and vomiting from anesthesia and surgery. The nurse should notify the healthcare provider if the medication is ineffective. The patch should be applied behind the ear and should remain in place to reduce the nausea and vomiting. Nausea and vomiting are no side effects of the medication.
387. The nurse identifies an electrolyte imbalance, an elevated pulse rate, and elevated BP for a client with chronic kidney disease. Which is the most important action for the nurse to take?
Monitor daily sodium intake.
Record usual eating patterns.
Measure ankle circumference.
Auscultate for irregular heart rate.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Rational: Chronic kidney failure (CKF) is a progressive, irreversible loss of kidney functions, decreasing glomerular filtration rate (GFR), and the kidney’s inability to excrete metabolic waste products and water, resulting in fluid overload, elevated pulse, elevated BP and electrolytes imbalances. The most important action for the nurse to implement is to auscultate for irregular heart rate (D) due to the decreased excretion of potassium by the kidneys. (A, B, and C) are not as important as monitoring for fatal cardiac dysrhythmias related to hyperkalemia.
388. A client with persistent low back pain has received a prescription for electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond?
Determine if the sensation feels uncomfortable.
Decrease the strength of the electrical signals.
Remove electrodes and observe for skin redness.
Check the amount of gel coating on the electrodes.
Rational: electronic stimulators, such as a transelectrical nerve stimulator (TENS) unit, have been found to be effective in reducing low back pain by ―closing the gate‖ to pain stimuli. A tingling sensation should be felt when the power is turned on, and the nurse should assess whether the sensation is too strong, causing discomfort or muscle twitching. Decreasing the electrical signal may be indicated if the sensation is too strong. Other options are not necessary because the tingling sensation is expected.
389. A female client is extremely anxious after being informed that her mammogram was abnormal and needs to be repeated. Client is tearful and tells the nurse her mother died of breast cancer. What action should the nurse take?
Provide the client with information about treatment options for breast cancer.
Reassure the client that the final diagnosis has not been made.
Encourage the client to continue expressing her fears and concerns.
Suggest to the client that she seek a second opinion.
Rational: the nurse should show support for the client by encouraging her to continue expressing her concerns. A diagnosis has not yet been made, so it is too early to discuss treatment options. Other options dismiss the client’s feelings or are premature given that the diagnosis is not yet made.
390. The psychiatric nurse is talking to a newly admitted client when a male client diagnosed with antisocial behavior intrudes on the conversation and tells the nurse, ―I
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) have to talk to you right now! It is very important!‖ how should the nurse respond to this client?
Put his behavior on extinction and continue talking with the newly admitted.
Inform him that the nurse is busy admitting a new client and will talk to him later.
Encourage him to go to the nurse’s station and talk with another nurse.
Introduce him to the newly admitted client and ask him to him to join in the conversation.
Rational: the psychiatric nurse must set limits with antisocial behavior so that appropriate behavior is demonstrated. Interrupting a conversation is rude and inappropriate, so telling the client that they can talk later is the best course of action. Other options may cause the client to become angry and they do not address the client’s behavior. The nurse should not involve this client with newly admitted client’s admission procedure.
391. The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN?
A 64 year old client who had a total hip replacement the previous day.
A 75 year old client with renal calculi who requires urine straining.
An adolescent with multiple contusions due to a fall that occurred 2 days ago.
A 30 year old depressed client who admits to suicide ideation.
RATIONALE: A client who is suicidal requires psychological assessment, therapeutic communication and knowledge beyond the educational level of a practical nurse (RN). Other clients could be cared for by the PN or the UAP, with supervision by the registered nurse.
392. A female client presents in the Emergency Department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask?
Does she knows the person who raped her?
Has she taken a bath since the raped occurred?
Is the place where she lived a safe place?
Did she report the rape to the police Department?
RATIONALE: The priority action is collected the forensic evidence, so asking if the has taken a bath since the rape occurred is the most important information to
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) obtain. Other options are used by law enforcement to determine the perpetrator and are not vital in providing client care at this time. 393. While caring for a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client’s laboratory values?
Serum albumin
Creatinine level
Culture for sensitive organisms.
Serum blood glucose (BG) level
RATIONALE: A client who has a postoperative dressing with purulent drainage from the wound is experiencing an infection. The nurse should review the client’s laboratory culture for sensitive organisms (C) before reporting to the healthcare provider. (A, B and D) are not indicated at this time.
394. The nurse is demonstrating correct transfer procedures to the unlicensed assisted personnel (UAP) working on a rehabilitation unit. The UAPs ask the nurse how to safely move a physically disabled client from the wheelchair to a bed. What action should the nurse recommended?
Hold the client at arm’s length while transferring to better distribute the body weight.
Apply the gait belt around the client’s waits once standing position has been assumed.
Place a client’s locked wheelchair on the client’s strong side next to the bed.
Pull the client into position by reaching from the opposite side of the bed.
RATIONALE: Placing the wheelchair on the client’s strong side offers the greatest stability for the transfer. Holding the client arm’s length or pulling from the opposite site of the bed reflect poor body mechanism. Using a gait belt offers additional safety for the client, but should be done after the wheelchair has be put into the proper place and the wheels have been locked and before the client has assumed a standing position.
395. A client who is experiencing musculoskeletal pain receives a prescription for ketorolac 15mg IM q6 hours. The medication is depended in a 39mg/ml pre-filled syringe. Which action should the nurse implement when giving the medication?
Administer the entire pre-filled syringe deep in the dorsogluteal site.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Use a separate syringe to remove 15mg from the pre-filled syringe and give in the back of the arm.
Waste 0.5 ml from the pre-filled syringe and inject the medication in the ventrogluteal site.
Call the healthcare provider to request a prescription change to match the dispensed 30mg dose.
RATIONALE: The pre-filled contain 30mg /1ml, so 0.5ml should be wasted to obtain the correct dosage of 15mg for administration in the preferred IM ventrogluteal site. The nurse is responsible for calculating and preparing the prescribed dose using the available concentration, so other options are not indicated.
396. A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO q 12hours. When the client request an afternoon snack, which dietary choice should the nurse provide?
Vanilla-flavored yogurt
Low fat chocolate milk.
Calcium fortified juice
Cinnamon applesauce
RATIONALE: Dairy products and calcium fortified dairy products decrease the absorption of ciprofloxacin. Cinnamon applesauce contains no calcium, so this is the best snack selection. Since other options contains calcium, these snack should be avoided by a client who is taking ciprofloxacin.
397. The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection would indicate to the nurse the client understands they prescribed diet?
Roasted turkey canned vegetables
Baked potatoes with skin raw carrots
Pancakes whole-grain cereal's
Roast pork fresh strawberries
Rationale: Foods allowed on a low-fiber diet includes roasted or baked turkey and canned vegetables the foods in the other options are not low in fiber
398. An adult client with schizophrenia begin treatment three days ago with the Antipsychotic risperidone. The client also received prescription for trazodone as needed
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) for sleep and clonazepam as needed for severe anxiety. When the client reports difficulty with swallowing, what action should the nurse take?
Obtain a prescription for an anticholinergic medication
Determine how many hours declined slept last night
Administer the PRN prescription for severe anxiety
Watch the thyroid cartilage move while the client swallows
Rationale: Antipsychotic medications have an extrapyramidal side effects one of which is difficult to swallowing the nurse should obtain a prescription for an anticholinergic medication which is used for the treatment of extrapyramidal symptoms. Other options are not warranted actions based on the symptoms presented.
399. One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in the clients plan of care?
Encourage Progressive active range of motion
Teach need for dietary and supplementary vitamin D3
Explain the need for skin exposure to sunlight without sunscreen
Instruct the client to use of muscle strengthening exercises
Rationale: Burn injury results in the acute loss of bone as well as the development of progressive vitamin D deficiency because burn scar tissue and adjacent normalappearing skin cannot convert normal quantities of the precursors for vitamin D3 that is synthesized from ultraviolet sun rays which is needed for strong bones. Clients with a history of full thickness burns should increase their dietary resources of vitamin D and supplemental D3 (B). range of motion (A) and muscle strengthening exercises (D) do not treat he underlying causes of the bone pain and weakness unprotected sunlight (C) should be avoided.
400. When teaching a group of school-age children how to reduce the risk of Lyme disease which instruction should the camp nurse include?
Wash hands frequently
Avoid drinking lake water
Wear long sleeves and pants
Do not share personal products
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Rationale: Lyme disease is it tick bone disorder and is transmitted to a child via a tick bite. Keeping the skin covered reduces the risk of being bitten by a tick. Other options are not reduce the risk for tick bites.
401. A native-American male client diagnosed with pneumonia, states that in addition to his prescribed medical treatment of IV antibiotics he wishes to have a spiritual cleaning performed. Which outcome statement indicates that the best plan of care was followed?
Identifies his ethnocentric values and behaviors
States an understanding of the medical treatment
Participated actively in all treatments regimens
Expresses a desire for cultural assimilation
Rationale: indicates active participation by the client, which is required for treatment to be successful. The best plan of care should incorporate the valued and treatments of both cultures and in this case there is no apparent cultural clash between the two forms of treatment. The client has already identify he's cultural values (A). (B) Only considers one of the two treatment modalities desired by the client the client has already chosen how he wishes to assimilate his cultural values with the prescribed medical treatment (D).
402. A male client with cancer is admired to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client’s admission prescription include radiation therapy. What action should the nurse implement?
Ask the client about his expected goals for the hospitalization
Explain the palliative care measures can be provided at home
Notify do radiation department to withhold the treatment for now
Determine if the client wishes to cancel further radiation treatment
Rationale: Palliative care measures provide relief or control of symptoms, so it is important for the nurse to determine the client’s goals for symptom control while receiving treatment in the hospital. Although home care is available the client may not be legible for palliative care at home. Radiation therapy is an effective positive care measure used to manage symptoms and would be appropriate unless the radiation conflicts with the client goals.
403. A client with myasthenia Gravis (MG) is receiving immunosuppressive therapy. Review recent laboratory test results show that the client’s serum magnesium level has
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?
Check the visual difficulties
Note most recent hemoglobin level
Assessed for he and Hand joint pain
Observe rhythm on telemetry monitor
Rationale: If not treated a low little Serum magnesium level can affect myocardial depolarization leading to a lethal arrhythmia, and the nurse should assess for dysrhythmias before contacting the healthcare provider. Other choices are common in MG but do not contribute the Safety risk of low magnesium levels.
404. A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?
Pain scale rating at 9 on a 0-10 scale
Last menstrual period was 7 weeks ago
Reports white curdy vaginal discharge
History of irritable bowel syndrome IBS
Rationale: Acute lower abdominal pain in A young adult female can be indicative of an ectopic pregnancy, which can be life threatening. Since the clients last menstrual period was seven weeks ago a pregnancy test to be obtained to ruled out ectopic pregnancy, which can result in intra-abdominal hemorrhage caused by a ruptured Fallopian tube. Although the severity of pain requires treatment, the most significant finding is the clients last menstrual period. Other options are not the most important concerns.
405. A 154 pound client with diabetic ketoacidosis is receiving an IV of normal saline 100 ML with regular insulin 100 units. The healthcare provider prescribes a rate of 0.1 units/kg/hour. To deliver the correct dosage, the nurse should set the infusion pump to Infuse how many ml/hour? enter numeric value only
7
Rationale: Convert the client’s weight to kg, 2.2 pound: 1 kg:: 154 pounds: x kg = 154/2.2 = 70kg. Calculate the client infusion rate, 0.1 x 70 kg = 7 units/hour. Using the formula, D/H x Q = 7 units/hour / 100 units x 100 ml = 7ml / hour
406. The nurse is assessing a postpartum client who is 36 hours post-delivery. Which finding should the nurse report to the healthcare provider?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
White blood count of 19,000 mm3
Oral temperature of 100.6 F
Fundus deviated to the right side
Breasts are firm when palpated
Rationale: A temperature greater than 100.4 F (38 C) (B), which is indicative of endometriosis (infection of the lining of the uterus), should be reported to the health care provider. (A and D) are findings that are within normal limits in the postpartum period. Fundal deviation to one side (C) is an expected finding related to a full bladder, so the nurse should encourage the client to void.
407. A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse?
Low-grade fever, headache, and malaise for the past 72 hours
Unable to bear weight on the left foot, with the swelling and bruising
Chest discomfort one hour after consuming a large, spicy meal
One-inch bleeding laceration on the chain of the crying five-year-old
Rationale: Emergency triage involves quick assessment to prioritize the need for further evaluation and care. Those with trauma, chest pain, respiratory distress, or acute neurological changes are priority. In this example, while clients with other conditions require attention, the client with chest discomfort is at greatest risk and is a priority.
408. The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and threaty. What action should the nurse take?
Document that an accurate oxygen saturation reading cannot be obtained
Elevate to client's hands for five minutes prior to obtaining a reading from the finger
Increase the oxygen based on the clients breathing patterns and lung sounds
Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading
Rationale: Pulse oximeter clips can be attached to the earlobe to obtain an accurate measurement of oxygen saturation. Other options will not provide the needed assessment.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 409. A young adult male who is being seen at the employee health care clinic for an annual assessment tell the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficulty indeed. Which response is best for the nurse to provide?
Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.
Encourage the client to seek genetic counseling to determine his risk for mental illness.
Informed the client that his mother schizophrenic has affected his psychological development.
Tell the client that mental illness has a familial predisposition so he should see a psychiatrist.
410. A client on a long-term mental health unit repeatedly takes own pulse regardless of the circumstance. What action should the nurse implement?
Overlook the client’s behavior.
Distract client to interfere with the ritual.
Ask why the client checks the pulse.
Hold client’s hand to stop the behavior.
411. A client is discharged with automated peritoneal dialysis (PD) to be used nightly…which instructions should the nurse include?
Wash hands before cleaning exit site
Keep the head of the bed flat at night
Feel for a thrill and a distal pulse nightly
Do not get up if fluid is left in the abdomen
412. The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse?
Opening the package
Picking up the second glove
Picking up the first glove
Positioning of the table
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 413. A male client reports to the clinic nurse that he has been feeling well and is often ―dizzy‖ his blood pressure is elevated. Based on this findings, this client is at a greatest risk for which pathophysiological condition?
Stroke
Renal failure
Left ventricular hypertrophy
Pulmonary hypertension
414. The nurse ask the parent to stay during the examination of a male toddler’s genital area. Which intervention should the nurse implement?
Examine the genitalia as the last part of the total exam.
Use soothing statements to facilitate cooperation
Allow the child to keep underpants on to examine genitalia
Work slowly and methodically so not to stress the child
415. The nurse is changing a client’s IV tubing and closes the roller clamp on the new tubing setup when the bag of solution is….which action should the nurse take to ensure adequate filling of the drip chamber?
Lower the IV bag to a flat surface
Compress the drip chamber
Open the roller clamp
Squeeze the bag of IV solution
416. …An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar…in addition to the client’s glucose, which laboratory value is most important for the nurse to monitor?
Serum potassium
Urine ketones
Urine albumin
Serum protein
417. A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Altered consciousness within the first 24 hours after injury.
Cushing reflex and cerebral edema after 24 hours
Fever, nuchal rigidity and opisthotonos within hours
Headache and pupillary changes 48 hours after a head injury
418. In planning strategies to reduce a client's risk for complications following orthopedic surgery, the nurse recognizes which pathology as the underlying cause of osteomyelitis?
infectious process
metastatic process
autoimmune disorder
inflammatory disorder
419. A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three times daily two months ago. Which finding provides the best indication that the medication regimen is effective?
The family reports a great reduction in client’s maniac behavior
420. Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client’s arm?
Assess IV site frequently for signs of extravasation
421. A client with a serum sodium level of 125 meq/mL should benefit most from the administration of which intravenous solution?
0.9% sodium chloride solution (normal saline)
0.45% sodium chloride solution (half normal saline)
10% Dextrose in 0.45% sodium chloride
5% dextrose in 0.2% sodium chloride
422. A client with Alzheimer’s disease falls in the bathroom. The nurse notifies the charge nurse and completes a fall follow-up assessment. What assessment finding warrants immediate intervention by the nurse?
Urinary incontinence
Left forearm hematoma
Disorientation to surroundings
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Dislodge intravenous site
Rationale: The left forearm hematoma may be indicative an injury, such as broken bone, that requires immediate intervention. A may be likely be due to the inability to use the toilet due to the fall. Disorientation is a common symptom of Alzheimer’s disease. IV Dislodged is not an urgent concern.
423. The nurse is triaging clients in an urgent care clinic. The client with which symptoms should be referred to the health care provider immediately?
headache, photophobia, and nuchal rigidity
high fever, skin rash, and a productive cough
nausea, vomiting, and poor skin turgor
malaise, fever, and stiff, swollen joints
Rationale: Headache, photophobia, and nuchal rigidity are classic signs of meningeal infection, so this client should immediately be referred to the health care provider. AC D do not have priority of B
424. An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?
Rebound abdominal tenderness
nausea and projectile vomit
rib pain with deep inspiration
diminished bilateral breath sounds
Rationale: Projective vomiting is indicative of increasing intracranial pressure, which can lead to ischemic brain damage or death, so this finding warrants immediate intervention. Rebound abdominal tenderness may indicate internal bleeding. Diminished breath sound may be related to pain. Rib pain with inspiration may indicate rib fracture.
425. After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client’s superior vena cava. Which action should the nurse implement?
Initiate intravenous fluid as prescribed
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Notify the HCP of the need to reposition the catheter
Remove the catheter and apply direct pressure for 5 minute
Secure the catheter using aseptic technique
Rationale: Venous blood return to the heart and drains from the subclavian vein into the superior vena cava. The X-ray findings indicate proper placement of the CVC, so prescribed intravenous fluid can be started. A and B are not indicated at this time. The catheter should be secure immediate following insertion (C)
426. The nurse has received funding to design a health promotion project for AfricanAmerican women who are at risk for developing breast cancer. Which resource is most important in designing this program?
A listing of African-American women so live in the community
Participation of community leaders in planning the program
Morbidity data for breast cancer in women of all races
Technical assistance to produce a video on breast self-examination.
Rationale: When developing a culturally-competent health promotion project, the participation of stakeholders and community leaders is most important. A and B might be useful background information, but t=first the program should be developed. D may be useful fulfilling the plan developed by the health care team and the community leaders if funding for this assistance is included in the budget.
427. The home care nurse provide self-care instruction for a client chronic venous insufficiency cause by deep vein thrombosis. Which instructions should the nurse include in the client’s discharge teaching plan? Select all that apply
Avoid prolonged standing or sitting
Use recliner for long period of sitting
continue wearing elastic stocking
Maintain the bed flat while sleeping
Cross legs at knee but not at ankle
428. The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?
Lip smacking and frequent eye blinking
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Shuffling gait and stooped posture
Rocks back and forth in the chair
Muscle spasms of the back and neck
Rationale: An extra pyramidal symptom (EPS) characterized by abnormal muscle spasms of the neck (A) requires immediate intervention because it can cause difficulty swallowing and jeopardize the airway. Though (A, B and C) are also EPS caused by antipsychotic medication medications used to manage schizophrenia (D) has the highest priority to insure client safety is (A)
429. A male client was transferred yesterday from the emergency department to the telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor alarms for ventricular tachycardia (VT), what action should the nurse take first?
Determine the client’s responsiveness and respirations
Bring the crash cart to the room to defibrillate the client.
Immediately initiate chest compressions.
Notify the emergency response team
Rationale: Activities, such as brushing teeth, can mimic the waveform of VI, so first he client should be assessed (A) to determine if the alarm is accurate. The crash cart can be brought to the room by someone else and defibrillation (B) delivered as indicated by the client’s rhythm. Based on as assessment of the client, CPR© as summoning the emergency response team (D) may be indicated.
430. A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse?
431.
The client has asymmetrical chest wall expansion
The clients complain of pain at the insertion site
The client chest’s x-ray indicates decreased pleural effusion
The client’s arterial blood gases are pH 7.35, PaO2 85, Pa CO2 35, HCO3 26
Rationale: A potential complication of thoracentesis is a pneumothorax. The symptoms of a pneumothorax are uneven, unequal movement of the chest wall. A is an expected finding after the local anesthetic effects “wear off” B is a desired result of thoracentesis and C is within normal limits. A client is receiving an IV solution labeled Heparin Sodium 20,000 Units in 5% dextrose
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) injection 500 ml at 25 ml/hour. How many units of heparin is the client receiving each hour?
1000 units/hour
Rationale:20000/500=40x25=1000
432. The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client’s discharge teaching plan?
Monitor for an elevated temperature
Measure the abdominal girth daily
Report the onset of sclera jaundice
Keep a record of daily urinary output
Rationale: The client should be instructed to monitor or elevated temperature because immunosuppressant agents, which are prescribed to reduce rejection after transplantation, place the client at risk for infection. The client should recognize sign of liver rejection, such as sclera jaundice and increasing abdominal girths, but fever may be the only sign of infection. A is not as important and monitoring for signs of infection.
433. The nurse is conducting health assessments. Which assessment finding increases a 56year-old woman’s risk for developing osteoporosis?
Body mass index of (BMI) of 31
20 pack-year history of cigarette smoking
Birth control pill usage until age 45
Diabetes mellitus in family history
Rationale: Cigarette smoking (2 packs/day x 310 years = 20 packs-year) increases the risk of osteoporosis. BMI of 30 or greater falls in the category of obesity which increase weight bearing that is protective against osteoporosis. C contain estrogens, and are also protective against development of osteoporosis. D is not related to the development of osteoporosis.
434. A young couple who has been unsuccessful in conceiving a child for over a year is seen in the family planning clinic. During an initial visit, which intervention is most important for the nurse to implement?
Determine current sexual practice
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Prepare a female client for an ultrasound
Request an sperm sample for ovulation
Evaluate hormone levels on both client
Rationale: First a history should be obtained including practices that might be related to the infertility, such as douching, daily ejaculation or the male partner’s exposure to heat, such as frequent sauna or work environment which can decrease sperm production (A B or C) may be indicated after a complete assessment is obtained.
435. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider?
Decreased white blood cell count
Pruritus and muscle aches
Elevated liver function tests
Vomiting and diarrhea
Rationale: Elevated liver function enzymes are a serious side effect of antivirals and should be reported. A decrease white blood count is a consistent finding with shingle B and (C and D) are side effects that affect that are of less priority than A.
436. A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first?
Review the heart rhythm on cardiac monitors
Check urinary catheter for obstruction
Auscultated bilateral breath sounds
Give PRN dose of lorazepam (Ativan)
Rationale: Restlessness often results from decreased oxygenation so breath sounds should be assessed first. Giving an anxiolytic such as lorazepam, might be indicated but first the client should be assessed for the cause of the restlessness. An obstruction in the urinary drainage system can cause a distended bladder that may result in restlessness, but patent airway is the priority intervention. The client should be assessed before evaluating the cardiac rhythm on the monitor.
437. The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer’s disease. The nurse observes
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation?
Tell the UAP to offer more choices during the personal care to prevent anxiety
Meet with the UAP later to role model more assertive communication techniques
Assume care of the client to ensure that effective communication is maintained.
Affirm that the UAP is using and effective strategy to reduce the client’s anxiety.
Rationale: Reduction is an effective technique is managing the anxiety of client with Alzheimer’s disease, so the nurse should affirm the UAP is using an effective strategy (A). Nurse assertive communication and offering more choices (B) may increase… an agitation (C) is not indicated since the UAP is using redirection, an effective strategy.
438. An older female who ambulate with a quad-cane prefer to use a wheel chair because she has a halting and unsteady gait at times. Which interventions should the nurse implement? (Select all that apply)
Move personal items within client’s reach
Lower bed to the lower possible position
Give directions to call for assistance
Assist client to the bathroom in 2 hours.
Encourage the use of the wheelchair
Raise all bed rails when the client is resting
Rationale: A client who needs assistive devices, such as quad-cane is at risk for falls. Precautions that should implement include ensuring that personal items are within reach the bed is in the lowest position and directions are given to call assistance to minimize the risk for falls. Frequently assisting the client to the bathroom help ensure this client does not go the bathroom by herself, thereby decreasing the possibility of falling.
439. In evaluating the effectiveness of a postoperative client’s intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?
Evaluate the client’s ability to use an incentive spirometer
Monitor the amount of drainage from the client’s incision
Observe both lower extremities for redness and swelling
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Palpate all peripheral pulse points for volume and strength
Rationale: Intermittent compression devices (ICDs) are used to reduce venous stasis and prevent venous thrombosis in mobile and postoperative clients and its effectiveness is best assessed by observing the client’s lower extremities for early signs of thrombophlebitis.
440. A school-age child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine (Phenergan) 0.5 mg/kg IM to prevent postoperative nausea. The medication is available in 25 mg/ml ampules. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth).
0.4
Rationale: Convert pounds to kg 42lbs = 19.09 kg
Next calculate to prescribed dose, 0.5 mg x 1909 kg = 9.545
Then use the desired dose/ dose on hand x volume on hand (9.545/25x1ml =0.3818=0.4 ml)
Or use ratio proportion (9.545 mg: x ml = 25 mg: 1ml
25x = 9.545
X= 0.3818 = 0.4)
441. A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. It is raining, no one is available to send for help, and the cell phone is in the car about 50 feet away. What action should the nurse take first?
Examine the victim’s body surfaces for arterial bleeding
Stabilize the victim’s neck and roll over to evaluate his status
Return to the car to call emergency response 911 for help
Open the airway and initiate resuscitative measures
442. During a well-baby, 6-month visit, a mother tells the nurse that her infant has had fewer ear infections than her 10-year-old daughter. The nurse should explain that which vaccine is likely to have made the difference in the siblings’ incidence of otitis media?
Varicella Virus Vaccine Live
Hemophilic Influenza Type B (HiB) vaccine
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Pneumococcal vaccine
Palivizumab vaccine for RSV
443. The healthcare provider prescribes Morphine Sulfate Oral Solution 38 mg PO q4 hours for a client who is opioid-tolerant. The available 30 mL bottle is labeled, 100 mg/5 mL (20mg/mL), and is packaged with a calibrated oral syringe to provide to provide accurate dose measurements. How many mL should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.) 1.9
Rationale: D/H x Q 38/20x1=1.9 mL
444. The nurses observes that a postoperative client with a continuous bladder irrigation has a large blood clot in the urinary drainage tubing. What actions should the nurse perform first?
Observe the amount of urine in the client’s urinary drainage bag
445. Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma?
Intravenous administration of thyroid hormones
Oral administration of hypnotic agents
Intravenous bolus of hydrocortisone
Subcutaneous administration of vitamin k
Rationale: The high mortality of myxedema coma requires immediate administration of IV thyroid hormones (A). (B) Is contraindicated, because eves small doses can cause profound somnolence lasting longer than expected. (C) Is administered to clients diagnosed with adrenal insufficiency (Addisonian crisis) and (D) to clients who have had an overdose of warfarin.
446. The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignments is best for the nurse to give this nurse?
Transfer a client to another unit
Monitor the central telemetry
Perform the admission
Assist cardiac nurses with their assignments
Rationale: When receiving staff from another specialty unit, the charge nurse should
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) allow the nurse to assist where possible (D) without taking a client assignment so that the nurse is not asked to perform unfamiliar skills (A, B, C) are likely to involve skills the nurse is not accustomed to performing. 447. A client who had an emergency appendectomy is being mechanically ventilated, and soft wrist restrain are in place to prevent self extubation. Which outcome is most important for the nurse to include in the client’s plan of care?
Understand pain management scale
Maintain effective breathing patterns
Absence of ventilator associated pneumonia
No injuries refer to soft restrains occur
Rationale: Basic airway management (B) is the priority. Pain management (A), risk of infection (C), and prevention of injury (D) do not have the same priority as (C)
448. After a routine physical examination, the healthcare admits a woman with a history of Systemic Lupus Erythematous (SLE) to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention by the nurse?
Blood pressure 170/98
Joint and muscle aches
Urine output 300 ml/hr
Dark, rust-colored urine
449. The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide?
450.
High salt can damage the lining of the blood vessels
Too much salt can cause the kidneys to retain fluid
Excessive salt can cause blood vessels to constrict
Salt can cause information inside the blood vessels
Rationale: Excessive salt intake can contribute to primary hypertension by causing renal salt retention which influence water retention that expands blood volume and pressure (ACD) are not believed to contribute to primary hypertension. In assessing a pressure ulcer on a client’s hip, which action should the nurse include?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Determine the degree of elasticity surrounding the lesion
Photograph the lesion with a ruler placed next to the lesion
Stage the depth of the ulcer using the Braden numeric scale
Use a gloved finger to palpate for tunneling around the lesion
Rationale: An ulcer extends into the dermis or subcutaneous tissue and is likely to increase in size and depth, so assessment should include photograph with measuring device to document the size of the lesion.
451. A nurse is planning discharge care for a male client with metastatic cancer. The client tells the nurse that he plans to return to work despite pain, fatigue, and impending death. Which goals is most important to include in this client’s plan of care?
Implements decisions about future hospices services within the next 3 months.
Marinating pain level below 4 when implementing outpatient pain clinic strategies.
Request home health care if independence become compromised for 5 days.
Arranges for short term counseling stressors impact work schedule for 2 weeks.
Rationale: An outpatient pain clinic provides the interdisciplinary services needed to manage chronic pain. Also the client has a terminal disease and is being discharge home, hospice and health care are not indicating at this time. Short term counseling is not an option.
452. The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image).
453. A client who had an open cholecystectomy two weeks ago comes to the emergency department with complaints of nausea, abdominal distention, and pain. Which assessment
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) should the nurse implement?
Auscultate all quadrant of the abdomen.
Perform a digital rectal exam
Palpate the liver and spleen
Obtain a hemoccult of the client’s stool
454. The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating
A paced rhythm with 100% capture after pacemaker replacement
Normal sinus rhythm and complaining of chest pain
Atrial fibrillation with congestive heart failure and complaining of fatigue
Sinus tachycardia 3 days after a myocardial infarction
455. A 12-lead electrocardiogram (ECG) indicates a ST elevations in leads V1 to V4, for a client who reports having chest pain. The healthcare provider prescribe tissue plasminogen activator (t-PA). Prior to initiating the infusion, which interventions is most important for the nurse to implement?
Complete pre-infusion checklist
456. The nurse is evaluating the health teaching of a female client with condyloma acuminate. Which statement by the client indicates that teaching has been effective?
Early treatment is very effective
I will clean my hot tub better
These warts are caused by a fungus
I need to have regular pap smears
457. While the nurse is conducting a daily assessment of an older woman who resides in a long-term facility, the client begins to cry and tells the nurse that her family has stopped calling and visiting. What action should the nurse take first?
Ask the client when a family member last visited her.
Determine the client’s orientation to time and space
Review the client’s record regarding social interactions
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Reassure the client of her family’s love for her
458. A female client with severe renal impairment is receiving enoxaparin (lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider?
creatinine clearance 25 mL/ minute
calcium 9 mg/dl
hemoglobin 12 grams/dl
partial thromboplastin time (PTT) 30 seconds
459. The nurse notes an increase in serosanguinous drainage from the abdominal surgical wound from an obese client. What action should the nurse implement?
Observe the wound for dehiscence
460. The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse’s immediate attention?
A 10-year-old who is receiving chemotherapy and the infusion pump is beeping
A young adult with Crohn’s disease who reports having diarrheal stools
An older adult with type 2 diabetes whose breakfast tray arrives 20 minutes late
A teenager who reports continued pain 30 minutes after receiving an oral analgesic
Rationale: an infiltration of a caustic agent can cause tissue damage and children are at greater risk for fluid volume imbalances
461. A nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual nutritional status?
462.
Condition of hair, nails, and skin
A 24-hour diet history
History of a recent weight loss
Status of current petite
Rationale: the assessment of hair, nails, and skin is most effective of long-term nutritional status, which is important in the healing process. The nurse is preparing to administer an infusion of amino acid-dextrose total parenteral
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) nutrition (TPN) through a central venous catheter (CVC) line. Which action should the nurse implement first?
Check the TPN solution for cloudiness
Attach the IV tubing to the central line
Set the infusion pump at the prescribed rate
Prime the IV tubing with TPN solution
463. A newly admitted client vomits into an emesis basin as seen in the picture. The nurse should consult with the healthcare provider before administering which of the client’s prescribes medications?
Clopidogrel (Plavix), an antiplatelet agent, given orally
Nitroglycerin (nitro-dur), an antianginal, to be given transdermally
Methylprednisolone (solu-medrol), a corticosteroid, to be given IV
Furosemide (lasix), a loop diuretic, to be given intravenously
Enoxaparin (lovenox), a low-molecular weight heparin to be given subcutaneous
464. A client diagnosed with bipolar disorder is going home on a week-end pass. Which suggestions should give the client’s family to help them prepare for the visit?
Encourage the family to plan daily activities to keep the client busy
Have friends and family visit the client at a welcome home party
Discuss the importance of continuing the usual at-home activities
Instruct family to monitor the client’s choice of television programs
465. On a busy day, one hour after the shift report is completed, the charge nurse learns that a female staff nurse who lives one hour away from the hospital forgot her prescription eye glasses at home. What action should the charge nurse take?
Encourage the nurse to purchase reading glasses in the hospital gift shop
Request another nurse to assist the staff nurse with her documentation
Ask the nurse to return home and get her prescription eyeglasses for work.
Tell the staff nurse to take a day off and change her weekly work schedule
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 466. A client with pneumonia has an IV of lactated ringer’s solution infusing at 30ml/hr current labor.…sodium level of 155 mEq/L, a serum potassium level of 4mEq/L…. what nursing intervention is most important?
Obtain a prescription to increase the IV rate
467. After teaching a male client with chronic kidney disease (CKD) about therapeutic diet…which menu of foods indicates that the teaching was effective? Select all that apply
A slice of whole grain toast
A bowl of cream of wheat
468. When five family members arrive at the hospital, they all begin asking the nurse questions regarding the prognosis of their critically ill mother. What intervention should the nurse implement first?
Include the family in client’s care
Request the chaplain’s presence
Ask the family to identify a specific spokesperson
Page the healthcare provider to speak with family.
469. An older male who is admitted for end stage of chronic obstructive pulmonary disease (COPD) tells the nurse …. The client provides the nurse with a living will and DNR. What action should the nurse implement?
Obtain a prescription for DNR
470. A client who is recently diagnosed with type 2 diabetes mellitus (DM) ask the nurse how this type of diabetes leads to high blood sugar. What Pathophysiology mechanism should the nurse explain about the occurrence of hyperglycemia in those who have type 2 DM?
The body cells develop resistance to the action of insulin.
471. During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate. Through the sheath to dissolve an occluded artery. Which interventions should the nurse implement?
Instruct the client to keep the left leg straight
Observe the insertion site for a hematoma
Circle first noted drainage on the dressing
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 472. A client whose wrists are sutured from a recent suicide attempt is been transferred from a medical unit. Which nursing diagnosis is of the highest priority?
Risk for self-directed violence related to impulsive actions
473. The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms?
Fruity breath odor
Polyphagia
Diaphoresis
Polydipsia
474. One day following a total knee replacement, a male client tells the nurse that he is unable to transfer because it is too painful. What action should the nurse implement?
Encourage use of analgesics before position change
475. The nurse is caring for a client with hypovolemic shock who is receiving two units of packed red blood cells (RBCs) through a large bore peripheral IV. What action promotes maintenance of the client’s cardiopulmonary stability during the blood transfusion?
Increase the oxygen flow via nasal cannula if dyspnea is present.
Place in a Trendelenburg position to increase cerebral blood flow
Monitor capillary glucose measurements hourly during transfusion.
Encourage increased intake of oral fluid to improve skin turgor.
476. A client with end-stage liver failure is declared brain dead. The family wants to discontinue feeding and donate any viable organs. Which action should the nurse take?
Contact the regional organ procurement agency
477. Which information is more important for the nurse to obtain when determining a client’s risk for (OSAS)?
Body mass index
Level of consciousness
Self-description of pain
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Breath sounds
478. During the transfer of a client who had major abdominal surgery this morning, the post anesthesia care unit (PACU) nurse reports that the client, who is awake and responsive continues to report pain and nausea after receiving morphine 2 mg IV and ondansetron 4 mg IV 45 mints ago. Which elements of SBAR communication are missing from the report given by the PACU nurse? (Select all that apply)
Situation
Background
Assessment
Recommendation
Rationales.
Rationale: BCD are correct. The current situation is reported regarding the client’s nausea and pain (A). Based on SBAR communication, critical information about the client’s clinical history (B), and assessment (C) such as pain scale or vital signs related to client’s response to medication, are not included, nor are any recommendations for further follow-up (D). (E) Is not a component of SBAR communication
479. The nurse is triaging victims of a tornado at an emergency shelter. An adult woman who has been wandering and crying comes to the nurse. What action should the nurse take?
Check the client’s temperature, blood sugar, and urine output.
Transport the client for laboratory client for laboratory test and electrocardiogram (EKG)
Delegate care of the crying client to an unlicensed assistant
Send the client to the shelter’s nutrient center to obtain water and food.
Rationale: According to the simple triage and Rapid Treatment (START) protocol of triage, the nurse should determine which client fit the objective of providing the greatest good for the greatest number of people who are most likely to survive. Delegating the care of the crying person to an unlicensed assistant allow the nurse to care for the injured who require intervention based on their ability to breath, maintain circulation and follow simple commands. A and B are not indicated at this time. Although food and water may be indicative, the woman’s distress should not be dismissed by sending her to the shelter alone.
480. A client in septic shock has a double lumen central venous catheter with one liter of 0.9% Normal Saline Solution infusing at 1 ml/hour through one lumen and TPN infusing at 50
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) ml/hr. through one port. The nurse prepared newly prescribed IV antibiotic that should take 45 mints to infuse. What intervention should the nurse implement?
Use a secondary port of the Normal Saline solution to administer the antibiotic.
Add the antibiotic to the TPN solution, and continue the normal saline solution.
Stop the TPN infusion for the time needed to administer the prescribed antibiotic.
Add the antibiotic to the Normal Saline solution and continue both infusions.
Rationale: A client in septic shock needs antibiotic administered in a timely manner to ensure maintenance of therapeutic serum level. The nurse should administer the antibiotic using a secondary port of the Normal Saline solution. No other medications should be administered using TPN tubing or solution. TPN not should be place on hold because sudden cessation will cause rapid change in serum glucose levels. Excessively delays in the administration of the antibiotics.
481. A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. What action I the treatment plan should the nurse implement?
Tell the client to drive over the bridge until fear is manageable
Teach client to listen to music or audio books while driving
Encourage client to have spouse drive in stressful places.
Recommend that the client avoid driving over the bridge.
Rationale: Desensitization is component in the treatment plan for clients with panic attacks which is best approached with anxiety-reducing strategies, such as listening to audio book (B) during situation that precipitate symptoms (A) is a flooding technique that requires professional guidance.
482. Which intervention should the nurse include in the plan of care for a client with leukocytosis?
483.
Avoid intramuscular injections
Monitor temperature regularly
Assess skin for petechiae or bruising
Implement protective isolation measures The nurse is teaching a client about the antiulcer medications ranitidine which was…
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) statement best describes the action of this drug?
It blocks the effects of histamine, causing decreased secretion of acid
Ranitidine will neutralize gastric acid and decrease gastric pH
This drug provides a protective coating over the gastric mucosa
It effectively blocks 97% of the gastric acid secreted in the stomach
484. A client with superficial burns to the face, neck, and hands resulting from a house fire…which assessment finding indicates to the nurse that the client should be monitored for carbon monoxide…?
Expiratory stridor and nasal flaring
Mucous membranes cherry red color
Carbonaceous particles in sputum
Pulse oximetry reading of 80 percent
485. A female client who was mechanically ventilated for 7 days is extubated. Two hours later…productive cough, and her respirations are rapids and shallow. Which intervention is most important?
Review record of recent analgesia
Provide frequent pulmonary toilet
Prepare the client for intubation
Obtain STAT arterial blood gases
486. The nurse delegates to an unlicensed assistive personnel (UAP) denture care for a client with…daily leaving. When making this assignment, which instruction is most important for the nurse to do?
Place a washcloth in the sink while cleaning the dentures
487. The nurse is assessing the emotional status of a client with Parkinson’s disease. Which client finding is most helpful in planning goals to meet the client’s emotional needs?
Cries frequently during the interview
Stares straight ahead without blinking
Face does not convey any emotion
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Uses a monotone when speaking
488. When changing a diaper on a 2-day-old infant, the nurse observes that the baby’s legs are… this finding, what action should the nurse take next?
Notify the healthcare provider
Continue care since this is a normal finding
Document the finding in the record
Perform range of motion to the joint
489. A school-aged child was recently diagnosed with celiac disease. Which instruction should the nurse give the classroom teacher?
The child should avoid eating homemade cookies and cupcakes during parties
490. The nurse is presenting information about fetal development to a group of parents with…when discussing cephalocaudal fetal development, which information should the nurse gives the parents?
A set order in fetal development is expected
Growth normally occurs within one organ at a time
Development progress from head to rump
Organ formation is directed by brain development
491. A client has a prescription for lorazepam 2mg for alcohol withdrawal symptoms. Which finding… the client?
Blood pressure 149/101
Irregular pulse rate of 80
Oral temperature is 98.9 F (37.1 C)
Pain rated 7 on scale 1-10
492. A client with end-stage liver failure is declared brain dead. The family wants to discontinue feeding and donate any viable organs. Which action should the nurse take?
Contact the regional organ procurement agency
493. A male client who was hit by a car while dodging through traffic is admitted to the emergency department with intracranial pressure (ICP). A computerized tomography (CT) scan
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) reveals an intracranial bleed. After evacuation of hematoma, postoperative prescription include: intubation with controlled mechanical ventilation to PaCO2…what is the pathophysiological basis for this ventilator settings?
Hypocapnea reduces ICP
494. During a cardiopulmonary resuscitation of an intubated client, the nurse detects a palpable pulse throughout the two minutes cycle chest compression and absent breath sounds over the left lung. What action should the nurse implement?
Prepare for the endotracheal tube to be repositioned
495. A male client is admitted with burns to his face and neck. Which position should the nurse place the client to prevent contract?
Hyperextended with neck supported by a rolled towel.
496. A male client is discharged from the intensive care unit following a myocardial infarction, and the healthcare provider low-sodium diet. Which lunch selection indicates to the nurse that this client understands the dietary restrictions?
Turkey salad sandwich.
Clam chowder
Macaroni and cheese
Bacon, lettuce, and tomato sandwich
497.
The nurse prepares an intravenous solution and tubing for a client with a saline lock, as seen in the video. Which nurse takes next
Open the roller clamp on the tubing.
498. The healthcare provider prescribes heparin protocol at18 units/kg/hr for a client with a possible pulmonary embolism. This client weighs 144 pounds. The available solution is labeled, heparin sodium 25,000 units in 5% dextrose 250 ml. the nurse should program the pump to deliver how many ml/hr? (Enter numeric value only. If rounding is require round to the nearest
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) whole number.)
Answer 12
Rationale: 144/2.2= 65kg
18units/kg/hr
65 kg x 18units/kg/hr= 1170 units/hr
25000 units heparin/250 ml of D5W = 100 units heparin per ml of solution
Formula D/H x A = X
499. A client is admitted with a wound on the right hand and associated cellulitis. In assessing the client’s hand, which finding required most immediate follow-up by the nurse?
Cyanotic nailbeds
Localized tenderness
Diffuse erythema
Skin hot to touch
500. The nurse is arranging home care for an older client who has a new colostomy following a large bowel resection three day. The clients plan to live with a family member. Which action should the nurse implement? Select all that apply
Assess the client for self-care ability
Provide pain medication instructions
Teach care of ostomy to care provider
501. A female client with chronic urinary retention explains double voiding technique to the nurse by stating she voids partially, hold the remaining urine in her bladder for three minutes, then voids again to empty her bladder fully. How should the nurse respond?
Advise the client to empty her bladder fully when she first voids
502. When conducting diet teaching for a client who was diagnosed with hypoparathyroidism, which foods should the nurse encourage the client to eat?
Yogurt.
Processed cheese.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Nuts
Fresh turkey
Fresh chicken
503. The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis. Which factor in this client’s history is a contributor to the osteoarthritis?
Long distance runner since high school.
Lactose intolerant since childhood
Photosensitive to a drug currently taking
Recently treated for deep vein thrombosis
504. When assessing a male client, the nurse notes that he has unequal lung expansion. What conclusion regarding this finding is most likely to be accurate? The client has
A collapsed lung
A history of COPD
A chronic lung infection
Normally functioning lungs
505. The nurse manager is conducting an in-services education program on the fire evacuation of the newborn recovery. What intervention should the nurse manager disseminate to the staff?
Evacuate each infant with mother via wheelchair
506. An adult man reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging in the neighborhood. He expresses concern because both of his deceased parents had heart disease and his father was a diabetic. He lives with his male partner, is a vegetarian, and takes atenolol which maintain his blood pressure at 138/74. Which risk factors should the nurse explore further with the client? Select all that apply
History of hypertension.
Family heath history.
507. A client with severe full-thickness burns is scheduled for an allografting procedure. Which information should the nurse provide the client?
Human source grafts require monitoring for signs of graft rejection
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 508. The nurse is administering a 750 ml cleansing enema to an adult client. After approximately150 ml of enema has informed, the client states, ‘stop I can’t hold anymore.” What action should the nurse take?
Clamp the tubing and instruct the client to breathe deeply before continuing.
509. The nurse requests a meals tray for a client follows Mormon beliefs and who is on clear liquid diet following abdominal surgery. Which meal item should the nurse request for this client? (Select all that apply)
Apple juice
Chicken broth.
Hot chocolate
Orange juice
Black coffee
510. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (LPN), and unlicensed assistant personnel (UAP). Which task should the charge nurse assign to the RN?
Supervised a newly hired graduate nurse during an admission assessment
511. Following breakfast, the nurse is preparing to administer 0900 medications to clients on a medical floor. Which medication should be held until a later time?
The mucosal barrier, sucralfate (Carafate), for a client diagnosed with peptic ulcer disease.
Rationale: Carafate coats the mucosal lining prior to eating a meal
512. The father of 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care?
Obtain a detailed report from the nurse transferring the client.
513. The nurse is making a home visit to a male client who is in the moderate stage of Alzheimer’s diseases. The client’s wife is exhausted and tells the nurse that the family plans to take turns caring for the client in their home, each keeping him for two weeks at a time. How should the nurse respond?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Suggest enrolling the client in adult daycare instead of rotating among family.
514. The healthcare provider prescribes oxycodone/ aspirin 1 tab PO every 4h as needed for pain, for a client with polycystic kidney disease. Before administering this medication, which component of the prescription should the nurse question?
Aspirin content.
Dose
Route
Risk for addiction
515. A young adult male was admitted 36 hours ago for a head injury that occurred as the result of a motorcycle accident. In the last 4 hours, his urine output has increased to over 200 ml/H. Before reporting the finding to the healthcare provider, which intervention should the nurse implement?
Evaluate the urine osmolality and the serum osmolality values.
516. A female client is taking alendronate, a bisphosphate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?
Report the client’s jaw pain to the healthcare provider.
517. A male client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client states he plans to take a multivitamin. What teaching should the nurse provide?
Be sure to take the multivitamin and the medication at least two hours apart for best absorption and effectiveness.
518. Which intervention should the nurse implement for a client with a superficial (first degree) burn?
Place wet cloths on the burned areas for short periods of time.
519. What is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)?
Achieve satisfactory pain control.
520. An adult woman who is seen in the clinic with possible neuropathic pain of the right leg rates her pain as a 7 on a 10 point scale. What action should the nurse take?
Encourage the client to describe the pain.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 521. A client has both primary IV infusion and a secondary infusion of medication. An infusion pump is not available. The nurse needs to determine the current rate of infusion of the primary IV. Where should the nurse observe to determine the rate of infusion?
522. The nurse is conducting the initial assessment of an ill client who is from another culture…. What response should the nurse provide? 523.
“What practices do you believe will help you heal?” The nurse is caring a client with NG tube. Which task can the nurse delegate to the UAP?
Disconnect the NG suction so the client can ambulate in the hallway
524. The nurse is collecting a sterile urine specimen using a straight catheter tray for culture…. (Arrange from first action to last). 1. Drape the client in a recumbent position for privacy 2. Open the urinary catheterization tray 3. Don sterile gloves using aseptic technique 4. Use forceps and swaps to clean the urinary meatus 525. The nurse is caring for a toddler with a severe birth anomaly that is dying. The parents… holding the child as death approaches. Which intervention is most important for the nurse?
Notify nursing supervisor and hospital chaplain of the child’s impending death.
526. The nurse is assessing a 4-year-old boy admitted to the hospital with the diagnosis of possible nephrotic syndrome. Which statement by the parents indicates a likely correlation to the child’s diagnosis?
“I couldn’t get my son’s socks and shoes on this morning”
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 527. Which interventions should the nurse include in a long-term plan of care for a client with COPD?
Reduce risk factors for infection
Limit fluid intake to reduce secretions
Use diaphragmatic breathing to achieve better exhalation
Administer high flow oxygen during sleep
528. A health care provider continuously dismisses the nursing care suggestions made by staff nurses. As a result…dealing with the healthcare provider. What action should the nursemanager implement?
Plan an interdisciplinary staff meeting to develop strategies to enhance client care
529. A 2-year-old girl is brought to the clinic for a routine assessment and all findings are within the normal limits. However, the mom expresses concern over her daughter’s protruding abdomen and tells the nurse that she is worry that her child is becoming overweight. How should the nurse respond to the mother’s comment?
Explain that a protruding abdomen is typical for toddlers
530. A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement?
Digitally check the client for a fecal impaction
531. A client admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) IIB IIIA inhibitor, which important finding places the client at greatest risk?
Unresponsive to painful stimuli
532. A toddler presents to the clinic with a barking cough, strider, refractions with respiration, the child's skin is pink with capillary refill of 2 seconds. Which intervention should the nurse implement?
Administered Nebulized Epinephrine
533. The nurse caring for a client with dysphagia is attempting to insert an NG tube, but the client will not swallow and is not gagging. What action should the nurse implement to facilitate the NGT passage into the esophagus? 534.
Flex the client’s head with chin to the chest and insert. The nurse plans to use an electronic digital scale to weight a client who is able to stand.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) Which intervention should the nurse implement to ensure that measurement of the client’s weight is accurate?
Ensure that the scale is calibrated before a weight is obtained
535. The nurse observes a newly hired unlicensed assistive personnel (UAP) performing a fingestick to obtain a client’s blood glucose. Prior to sticking the client’s finger, the UAP explains the procedure and tell the client that it I painless. What action should the nurse take?
Allow the UAP to complete the procedure, then discuss the painless comment privately with the UAP.
536. An African-American man come into the hypertension screening booth at a community fair. The nurse finds that is blood pressure is 170/94 mmHg. The client tells the nurse that he has never been treated for high blood pressure. What response should the nurse make?
Your blood pressure is a little high. You need to have it rechecked within one week
537. While attempting to stablish risk reduction strategies in a community, the nurse notes that the regional studies have indicated….persons with irreversible mental deficiencies due to hypothyroidism. The nurse should seek funding to implement which screening measure?
T4 levels in newborns
538. After applying an alcohol-based hand rub to the palms of the hand and rubbing the hand together, what action should the nurse do next?
Place one hand on top of the other and interlace the fingers
539. A nurse is preparing to feed a 2-month-old male infant with heart failure who was born with congenital heart defect. Which intervention should the nurse implement?
Allow the infant to rest before feeding
540. While removing an IV infusion from the hand of a client who has AIDS, the nurse is struck with the needle. After washing the puncture site with soap & water, which action should the nurse take?
Notify the employee health nurse.
541. A nurse receive a shift report about a male client with Obsessive compulsive disorder (OCD). The nurse does morning rounds and reaches the client while he is repeatedly washing the top of the same table. What intervention should the nurse implement? 542.
Allow time for the behavior and then redirect the clients to other activities The nurse is caring for a client immediately after inserting a PICC line. Suddenly, the
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) client becomes anxious and tachycardiac, and loud churning is heard over the pericardium upon auscultation. What action should the nurse take first?
Place client in Trendelenburg position on the left side.
543. A client admitted to the telemetry unit is having unrelieved chest pain after receiving 3 sublingual nitroglycerin tablets and morphine 8 mg IV. The electrocardiogram reveals sinus bradycardia with ST elevation. In what order should the nurse implement the nursing actions? (Arrange first to last) 1. Call the rapid response team to assist 2. Move the crash cart to the client room 3. Notify the client’s healthcare provider 4. Inform the family of the critical situation 544. The nurse is preparing dose # 7 of an IV piggyback infusion of tobramycin for a 73-yearol client with... Infected pseudomonas aeruginosa. Which assessment data warrants further intervention by the nurse?
Peak and through levels has not been drawn since the tobramycin was started
545. During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate…through the sheath to dissolve an occluded artery. Which interventions should the nurse implement?
Instruct the client to keep the left leg straight
Observe the insertion site for a hematoma
Circle first noted drainage on the dressing
546. A client with HIV and pulmonary coccidioidomycosis is receiving amphotericin B. which assessment finding should the nurse report to the healthcare provider?
Urinary output of 25mL per hour
547. A client delivers a viable infant, but begins to have excessive uncontrolled vaginal…notifying the health care provider of the clients’ condition, what information is most….
Maternal blood pressure
Maternal apical pulse rate
Time Pitocin infusion completed
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Total amount of Pitocin infused
548. An infant born to a heroin-addicted mother is admitted to the neonatal care unit. What behaviors can…to exhibit?
Irritability and a high-pitched cry
Lethargy and poor suck
Facial abnormalities and microcephaly
Low birth weight and intrauterine growth retardation
549. A multigravida, full-term, laboring client complains of “back labor”. Vaginal examination reveals that the client’s 3 cm with 50% effacement and the fetal head is at -1 station. What should the nurse implement?
Turn the client to a lateral position
Apply counter-pressure to the sacral area
Notify the scrub nurse to prepare the OR
Ambulate the client between contractions
550. A client with gestational diabetes is undergoing a non-stress test (NST) at 34-week gestation… is 144 beats/minute. The client is instructed to mark the fetal monitor by pressing a button each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. What…
Two FHR accelerations of 15 beats/minute x 15 seconds are recorded
551. A male infant born at 28-weeks gestation at an outlying hospital is being prepared for transport to a respiration are 92 breaths/minute and his heart rate is 156 beats/minute. Which drug is the transport administration to this infant?
Instill beractant 100 mg/kg in endotracheal tube.
552. A postpartal client complains that she has the urge to urinate every hour but is only able to void a small amount. What interventions provides the nurse with the most useful information?
Catheterize for residual urine after next voiding
Initiate a perineal pad count
Assess for a perineal hematoma
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Determine the client’s usual voiding pattern
553. During a 26-week gestation prenatal exam, a client reports occasional dizziness…What intervention is best for the nurse to recommend to this client?
Lie on the left or right side when sleeping or resting
554. Artificial rupture of the membrane of a laboring reveals meconium-stained fluid, what is… the priority?
Have a meconium aspirator available at delivery
555. A 6-year-old child with acute infectious diarrhea is placed on a rehydration therapy…Which action should the nurse instruct the parents to take if the child begins to vomit?
Continue giving ORS frequently in small amounts
556. A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important time the infusion rate is increases?
Contraction pattern
Blood pressure
Infusion site
Pain level
557. An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant tachypneic, and hypotonic. What is the first action that the nurse should take?
Determine the infant’s blood sugar level
558. A toddler with a history of an acyanotic heart defect is admitted to the pediatric intensive…rate of 60 breaths/ minute, and a heart rate of 150 beats/minute. What action should the nurse take?
Obtain a pulse oximeter reading
559. In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management? 560.
Enable clients to become active participants in controlling the disease process To obtain an estimate of a client’s systolic B/P. What action should the nurse take first?
Palpate the client’s brachial pulse
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Pump up the blood pressure cuff
Position the stethoscope diaphragm
Release the blood pressure cuff valve
561. A client is admitted to isolation with the diagnosis of active tuberculosis (TB). Which infection control measures should the nurse implement?
Negative pressure environment
Contact precautions
Droplet precautions
Protective environment
562. A client is receiving an IV of heparin sodium 25000 units in 5% dextrose injection 500 ml at 14 ml/hour…verify that the client is receiving the prescribed amount of heparin. How many units is the client receiving?700 563.
Rationale: 25000/500x14=700
564. A client currently receiving an infusion labeled Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 mL at 14 mL/hour. A prescription is received to change the rate of the infusion to 900 units of Heparin per hour. The nurse should set the infusion pump to deliver how many mL/hour? (Enter numeric value only). 18 Rationale: 450000/25000=18 565. The nurse notes the client receiving heparin infusion labeled, Heparin Na 25,000 Units in 5% Dextrose injection 500 ml at 50ml/hr. What dose of Heparin is the client receiving per hour?
2,500
566. A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a JacksonPratt bulb surgical drainage device is in place. Which interventions is most important for the nurse to include in this clients plan of care?
567.
Monitor urine output hourly.
Assess for back muscle aches
Record drainage from drain
Obtain body weight daily The family of a client who just died arrives on the nursing unit after receiving telephone
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) notification of the death. Several family members state they would like to view the body. How should the nurse respond?
Offer to go with the family members to view the body.
568. The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?
Moderate amount of foul-smelling lochia.
569. An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction & lens implantation. Which intervention is most important for the nurse to implement to ensure the client's compliance with self-care?
Have the client vocalize the instructions provided.
570. A primigravida client is 36 weeks gestation is admitted to labor and delivery unit because her membranes ruptured 30minutes ago. Initial assessment indicates 2cm dilation, 50% effaced, -2 station, vertex presentation greenish colored amniotic fluid, and contractions occurring 3-5 minutes with a low FHR after the last contraction peaks:
Administer Oxygen via face mask
Apply an internal fetal heart monitor
Notify the healthcare provider
Use a vibroacoustic stimulator
571. A woman just received the Rubella vaccine after a delivery of a normal new born, has two children at home, ages 13 months and 3 years. Which instruction is most important to provide to the client?
Do not get pregnant for at least 3 months
572. Following a motor vehicle collision (MCV), a male adult in severe pain is brought to the emergency department via ambulance. His injured left leg is edematous, ecchymotic around the impact of injury on the thigh, and shorter than his right leg. Based on these findings, the client is at greatest risk for which complication?
Arterial ischemia
Tissue necrosis
Fat embolism
Nerve damage
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 573. A 2-year-old is bleeding from a laceration on the right lower extremity that occurred as the result of a motor vehicle collision. The nurse is selecting supplies to start an IV access. Which assessment finding is most significant in the nurse's selection of catheter size?
Thready brachial pulse.
Respirations of 24/minute
Right foot cool to touch
Swelling at the site of injury
574. The nurse prepares to insert an oral airway by first measuring for the correct sized airway. Which picture shows the correct approach to airway size measurement?
575. A client with a recent colostomy expresses concern about the ability to control flatus. Which intervention is most important for the nurse to include in the client’s plan of care?
Adhere to a bland diet whenever planning to eat out
Decrease fluid intake at meal times
Avoid foods that caused gas before the colostomy
Eliminate foods high in cellulose
576. A male client arrives at the clinic with a severe sunburn and explains that he did not use sun screen because it was an overcast day. Large blisters are noted over his back and chest and his shirt is soaked with serosanguinous fluid. Which assessment finding warrants immediate intervention by the nurse?
Hypotension.
Fever and chills
Dizziness
Headache
577. A client with polycystic kidney disease (PKD) receiving antibiotics for an infected cyst is experiencing severe pain. What action should the nurse implement?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Hold the next dose of antibiotic until contacting the healthcare provider
Teach the client how to use a dry heating pad over the painful area
Encourage the client to practice pelvic floor exercises every hour
Assist the client to splint the site by applying an abdominal binder
578. Which statement is accurate regarding the pathological changes in the pulmonary system associated with acute (adult) respiratory distress syndrome (ARDS)?
Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema
A high ventilation-to-perfusion ratio is characteristic of affected lung fields in ARDS
Functional residual capacity and lung compliance increase as the disease progresses
Interstitial edema that occurs due to capillary fluid shifts is usually more serious than alveolar edema
579. The nurse mixes 250 mg of debutamine in 250 ml of D5W and plans to administer the solution at rate client weighing 110 pounds. The nurse should set the infusion pump to administer how many ml per hour only. If rounding is required, round the nearest whole number.)
45
580. During the intraoperative phase of care, the circulating nurse observes that the client is not adequately client's privacy. What is the best initial nursing action for the nurse to implement?
Instruct the scrub nurse to re-drape the client
581. An adult male who was admitted two days ago following a cerebrovascular accident (CVA) is confused and experiencing left-side weakness. He has tried to get out of bed several times, but is unable to ambulate without assistance. Which intervention is most important for the nurse to implement?
Ask a family member to sit with the client
Apply bilateral soft wrist restraints
Assign staff to check client q15 minutes
Install a bed exit safety monitoring device
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 582. A client in her first trimester of pregnancy complains of nausea. Which complementary therapy should the nurse recommend?
Drink chamomile tea at breakfast and in the evening.
Eat food high in garlic with the evening meal
Join a yoga class that meets at least weekly
Increase cocoa in the diet and drink before bedtime
583. When gathering for a group therapy session at 1400 hours, a female client complains to the nurse that a smoking break has not been allowed all day. The nurse responds that 15 minute breaks were called over the unit intercom after breakfast and after lunch. The nurse is using what communication technique in responding to the client?
Doubt
Observation
Confrontation
Reflection
584. A female client with rheumatoid arthritis (RA) comes to the clinic complaining of joint pain and swelling. The client has been taking prednisone (Deltasone) and ibuprofen (Motrin Extra Strength) every day. To assist the client with self-management of her pain, which information should the nurse obtain?
Presence of bruising, weakness, or fatigue
Therapeutic exercise included in daily routine.
Average amount of protein eaten daily
Existence of gastrointestinal discomfort
585. The charge nurse of the Intensive Care Unit is making assignments for the permanent staff and one RN who was floated from a medical unit. The client with which condition is the best to assign to the float nurse?
Diabetic ketoacidosis and titrated IV insulin infusion
Emphysema extubated 3 hours ago receiving heated mist
Subdural hematoma with an intracranial monitoring device
Acute coronary syndrome treated with vasopressors
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 586. A client admitted to the emergency center had inspiratory and expiratory wheezing, nasal flaring, and thick, tenacious sputum secretions observed during the physical examination. Based on these assessment findings, what classification of pharmacologic agents should the nurse anticipate administering?
Beta blockers
Bronchodilators
Corticosteroids
Beta-adrenergics
587. The home health nurse is assessing a male client who has started peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants immediate intervention by the nurse?
Finger stick blood glucose 120 mg/dL post exchange
Arteriovenous (AV) graft surgical site pulsations.
Anorexia and poor intake of adequate dietary protein
Cloudy dialysate output and rebound abdominal pain
588. A client’s telemetry monitor indicates ventricular fibrillation (VF). What should the nurse do first?
Administer epinephrine IV
Give an IV bolus of amiodarone
Provide immediate defibrillation
Prepare for synchronized cardioversion
589. In conducting a health assessment, the nurse determines that both parents of a child with asthma smoke cigarettes. What recommendation is best to the nurse to recommend to the parents?
590.
avoid smoking in the house
stop smoking immediately
decrease the number of cigarettes smoke daily
obtain nicotine patches to assist in smoking sensation A client who is schedule for an elective inguinal hernia repair today in day surgery is
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) seem eating in the waiting area. What action should be taken by the nurse who is preparing to administer the preoperative medications?
Review the surgical consent with the client
Explain that vomiting can occur during surgery
Remove the food from the client
Withhold the preoperative medication
591. The nurse is developing a plan of care for a middle-aged woman who is diagnosed with type 2 diabetes mellitus (DM). To lower her blood glucose and increase her serum high-density lipoprotein (HDL) levels, which instruction is most important for the nurse to provide?
Exercise at least three times weekly
Monitor blood glucose levels daily
Limit intake of foods high in saturated fat
Learn to read all food product labels
592. A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take?
Allow the client to use a bedpan.
Assist the client to the bathroom
Perform a sterile vaginal exam
Explain the fetal head is descending.
Rationale: When a client in active labor suddenly expresses the urge to have a bowel movement, a sterile vaginal exam should be performed to determine if the fetus is descending.
593. The nurse assesses a 78-year-old male client who has left sides heart failure. Which symptoms would the nurse expect this client to exhibit?
Dyspnea, cough, and fatigue.
Hepatomegaly and distended neck veins
Pain over the pericardium and friction rub.
Narrowing pulse pressure and distant heart sounds.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 594. A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can’t take her behavior any more since all she does is care for their son. What intervention should the nurse implement?
Schedule a home visit in the afternoon to assess the son and client role as caregiver.
Acknowledge the client’s stress and suggest that she consider respite care.
Provide feedback to the client about her atonement for guilt about her son’s impairment.
Teach the client to problem-solve for herself and establish her own priorities.
Rationale: When this amount of disclosure is offered, the client is usually seeking information focuses on the client’s expression of worry, concern and stress and addresses the client’s need to initiate a request for assistance with respite care.
595. The nurse plans to administer a schedule dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that client’s telemetry pattern shows a second degree heart block with a ventricular rate of 50. What action should the nurse take?
Administer the Tropol immediately and monitor the client until the heart rate increases.
Provide the dose of Tropol as scheduled and assign a UAP to monitor the client’s BP q30 minutes.
Give the Tropol as scheduled if the client’s systolic blood pressure reading is greater than 180.
Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern.
Rationale: Beta blockers such as metoprolol (Tropol SR) are contraindicated in clients with second or third degree heart block because they decrease the heart rate. Therefore, the nurse should hold the medication.
596. A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the health care provider?
Insomnia
Muscle cramping
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Increase appetite
Anxiety.
Rationale: SIADH causes dilution hyponatremia because of the increased release of ADH, which is treated with water restriction and demeclocycline, a tetracycline derivate that blocks the action of ADH. Signs of hyponatremia (normal 136-145), which indicate the need for increasing the dosage of demeclocycline, should be reported to the healthcare provider. The signs include: plasma sodium level less than 120, anorexia, nausea, weight changes related to fluid disturbance, headache, weakness, fatigue, and muscle cramping. AC& D are not related to hyponatremia.
597. In determine the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition?
High urinary PH
Abdominal Ascites
Orthopnea
Fever.
Rationale: If the client is orthopneic, the nurse needs to adapt the insertion position that does not place the client in a supine position (the head of the bed should be elevated as much as possible).
598. The nurse is reviewing a client’s electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate?
Initiation of the impulses from a location outside the SA node
Inability of the SA node to initiate an impulse at the normal rate
Increased conduction time from the SA node to the AV junction
Interference with the conduction through one or both ventricles.
Rationale: A prolonged PRI reflects an increased amount of time for an impulse to travel from the SA node through the AV node and is characteristic of a first degree heart block.
599. The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical areas of his abdomen. What instruction should the nurse provide?
Stroke the inner thigh below the perineum to initiate urinary flow
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Contract, hold, and then relax the pubococcygeal muscle
Pour warm water over the external sphincter at the distal glans
Apply downward manual pressure at the suprapubic regions.
Rationale: The Crede Method is used for those clients with atonic bladders, which is a concomitant of demyelinating disorders like multiple sclerosis. The client is applying pressure in the wrong region (umbilical Are) and should be instructed to apply pressure at the suprapubic are.
600. A 35 years old female client has just been admitted to the post anesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse’s accurate understanding of the expected outcome for the client following this surgery?
Supplemental hormonal therapy will probably be unnecessary
The thyroid will regenerate to a normal size within a few years.
The client will be restricted from eating seafood
The remainder of the thyroid will be removed at a later date.
601. A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first?
Prepare the client for an emergency cesarean birth
Encourage the client to move to a hands-and-knees position.
Assist the client to sharply flex her thighs up again the abdomen.
Lower the head of the bed an apply suprapubic pressure.
Rationale: Flexing the client’s thighs against the abdomen (Mc Robert’s maneuver) changes the angle o the pelvis and increase the pelvic diameter, making more room for the shoulders to emerge. ABD are implemented after C
602. The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic?
Low bioavailability
Rapid onset of action
Short half life
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Narrow therapeutic index.
Rationale: A drug with a narrow therapeutic index has a high risk for toxicity because there is a narrow range between the therapeutic dose and the toxic dose.
603. Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective?
Decrease abdominal girth
Increased blood pressure
Clear breath sounds
Decrease serum albumin.
604. When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do?
Check for any abrasions or bruises.
Help the client to stand.
Get a blood pressure cuff.
Report the fall to the nurse-manager.
605. During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?
Notify the pediatrician immediately.
Teach the parents about congenital heart defects.
Document the finding in the infant's record.
Apply oxygen per nasal cannula at 3 L/min.
606. Which assessment finding indicates to the nurse a client’s readiness for pulmonary function tests?
Expresses an understanding of the procedure.
607. A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L or 12 mmol/L (SI), and blood glucose is 310 mg/dl or 17.2 mmol/L (SI). Which action should the nurse implement?
Infuse sodium chloride 0.9% (normal saline)
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 608. The nurse is assessing the thorax and lungs of a client who is having respiratory difficulty. Which finding is most indicative of respiratory distress?
Contractions of the sternocleidomastoid muscle
609. After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?
Monitor mental status.
610. A client present at the clinic with blepharitis. What instructions should the nurse provide for home care?
Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo
611. Dopamine protocol is prescribed for a male client who weigh 198 pounds to maintain the mean arterial pressure (MAP) greater than 65 mmHg. His current MAP is 50 mmHg, so the nurse increases the infusion to 7 mcg/kg/minute. The infusion is labeled dextrose 5% in water (D5W) 500 ml with dopamine 400 mg. The nurse should program the infusion pump to deliver how many ml/hour?
47
612. The nurse is teaching a client with atrial fibrillation about a newly prescribed medication, dronedarone. Which information should the nurse include in client interactions? (Select all that apply)
Avoid eating grapefruit or drinking grapefruit juice.
Report changes in the use of daily supplements
Notify you heal care provider if your skin looks yellow
613. A male client recently released from a correctional facility arrives at the clinic with a cough, fever, and chills. His history reveals active tuberculosis (TB) 10 years ago. What action should the nurse implement? (Select all that apply)
Schedule the client for the chest radiograph
Obtain sputum for acid fast bacillus (AFB) testing
Place a mask on the client until he is moved to isolation.
614. A 16-year-old male is admitted to the pediatric intensive care unit after being involved in a house fire. He has full thickness burns to his lower torso and extremities. Before a dressing change to his legs, which intervention is most important for the nurse to implement?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Maintain strict aseptic technique.
615. While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition?
Tinea corporis
Herpes zoster
Psoriasis
Drug reaction
616. A client with acute pancreatitis is complaining of pain and nausea. Which interventions should the nurse implement (Select all that apply)
Monitor heart, lung, and kidney function.
Notify healthcare provider of serum amylase and lipase levels.
Review client’s abdominal ultrasound findings.
Position client on abdomen to provide organ stability
Encourage an increased intake of clear oral fluids
617. A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse?
Hypernatremia
Excessive thirst
Elevated heart rate
Poor skin turgor
618. In caring for a client receiving the amino glycoside antibiotic gentamicin, it is most important for the nurse to monitor which diagnostic test?
Serum creatinine
619. The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby’s weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer?
What food does your baby usually eat in a normal day?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
What was the baby’s weight at the last well-baby clinic visit?
The baby is below the normal percentile for weight gain
Your baby is gaining weight right on schedule
620. A client who is at 36 weeks gestations is admitted with severe preclampsia. After a 6 gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse? 621.
Urine output 20 ml/hour
622.
What is the nurse’s priority goal when providing care for a 2-year-old child experience…
Stop the seizure activity
Decrease the temperature
Manage the airway
Protect the body from injury
623. The nurse is preparing to discharge an older adult female client who is at risk for hy…nurse include with this client’s discharge teaching?
Report any muscle twitching or seizures
Take vitamin D with calcium daily
Low fat yogurt is a good source of calcium
Keep a diet record to monitor calcium intake
Avoid seafood, particularly selfish
624. The husband of a client with advanced ovarian cancer wants his wife to have every treatment available. When the husband leaves, the client tells the nurse that she has had enough chemotherapy and wants to stop all treatments but knows her husband will sign the consent form for more treatment. The nurse’s response should include which information?
625.
The husband cannot sign the consent for the client, her signature is required
The client’s specific wishes should be discussed with her healthcare provider
The healthcare team will formulate a plan of care to keep the client comfortable The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) insulin…medication?
Push the undiluted Dextrose slowly through the currently infusion IV
626. The daughter of an older female client tells the clinic nurse that she is no longer able to care for her mother since her mother has lost the ability to perform activities of daily living (ADLs) due to aging. Which options should the nurse discuss with the daughter?
Home hospice agency
Long-term care facility
Rehabilitation facility
Independent senior apartment
Home health agency
627. A male client with cancer, who is receiving antineoplastic drugs, is admitted to the…what findings is most often manifest this condition?
Ecchymosis and hematemesis
Weight loss and alopecia
Weakness and activity intolerance
Sore throat and fever
628. A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child’s vital signs and weight, what intervention should the nurse implement next?
Measure the child’s abdominal girth
Perform an ostoscopic examination
Collect a urine specimen for routine urinalysis
Obtain a blood specimen for serum electrolytes
629. The nurse observes an adolescent client prepare to administer a prescribed corticosteroid medication using a metered dose inhaler as seen in the picture. What action should the nurse take?
Remind the client to hold his breath after inhaling the medication
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Confirm that the client has correctly shaken the inhaler
Affirm that the client has correctly positioned the inhaler
Ask the client if he has a spacer to use for this medication
630. The nurse teaches an adolescent male client how to use a metered dose inhaler. Seen in the picture. What instruction should the nurse provide?
Move the device one to two inches away from the mouth
Secure the mouthpiece under the tongue
Press down on the device after breathing in fully
Breathe out slowly and deeply while compressing the device
631. A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother…During the assessment, the mother asks the nurse why her child is at the 5th percent…response is best for the nurse to provide?
Does your child seem mentally slower than his peers also?
“His smaller size is probably due to the heart disease”
Haven’t you been feeding him according to recommended daily allowances for children?
You should not worry about the growth tables. They are only averages for children
632. A client with hypertension receives a prescription for enalapril, an angiotensin…instruction should the nurse include in the medication teaching plan?
Increase intake of potassium-rich foods
Report increased bruising of bleeding
Stop medication if a cough develops
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Limit intake of leafy green vegetables
633. When administering ceftriaxone sodium (Rocephin) intravenously to a client before…most immediate intervention by the nurse?
Stridor
Nausea
Headache
Pruritis
634. The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider?
Rebound tenderness in the upper quadrants
Hypoactive bowel sounds in the lower quadrants
Tympany with percussion of the abdomen
Light colored gastric aspirate via the nasogastric tube
635. An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client’s handwashing is an example of which clinical behavior?
Addiction
Phobia
Compulsion
Obsession
636. A female client reports that she drank a liter of a solution to cleanse her intestines…immediately. How many ml of fluid intake should the nurse document? Whole number
760
Rationale: 1L=1000ml
Subtract the emesis, 1 cup (8 oz)=240ml
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
1000-240=760 ml
637. Following routine diagnostic test, a client who is symptom-free is diagnosed with Paget’s disease. Client teaching should be directed toward what important goal for this client?
Maintain adequate cardiac output
Promote adequate tissue perfusion
Promote rest and sleep
Reduce the risk for injury
638. The mother of a one-month-old boy born at home brings the infant to his first well…was born two weeks after his due date, and that he is a “good, quiet baby” who almost…hypothyroidism, what question is most important for the nurse to ask the mother?
Is your son sleepy and difficult to feed?
639. In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)?
An older client post-stroke who is aphasic with right-sided hemiplegia
640. Following a gun shot wound to the abdomen, a young adult male had an emergency bowel…Multiple blood products while in the operating room. His current blood pressure is 78/52…He is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values…Grams / dl (70 mmol / L SI), platelets 20,000 / mm 3 (20 x 10 9 / L (SI units), and white blood cells. Based on these assessments findings, which intervention, should the nurse implements first? 641.
Transfuse packed red blood cells After checking the fingerstick glucose at 1630, what action should the nurse implement?
Administer 8 units of insulin aspart SubQ
642. Progressive kyphoscoliosis leading to respiratory distress is evident in a client with muscul…Which finding warrants immediate intervention by the nurse?
Evidence of hypoventilation
643. An adult male who lives alone is brought to the Emergency Department by his daughter who is unresponsive. Initial assessment indicated that the client has minimal respiratory effort, and his pupils are fixed and dilated. At the daughter’s request, the client is intubated and…Which nursing intervention has the highest priority?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Determine if the client has an executed living will
644. The nurse determines that a client’s pupils constricts as they change focus from a far object. What documentation should the nurse enter about this finding? 645.
Pupils reactive to accommodation Which nursing intervention has the highest priority for a multigravida who delivered…
Assess fundal tone and lochia flow
646. A client who had a gestational trophoblastic disease (GTD) evacuated 2 days ago is being…18 months-old child and lives in a rural area. Her husband takes the family car to work daily…transportation during the day. What intervention is most important for the nurse to implement?
Schedule a weekly home visit to draw hCG values.
647. A newly graduated female staff nurse approaches the nurse manager and request reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?
I’ll change your assignment, but let’s talk about you a nurse should respond to this kind of client.
648. After removing a left femoral arterial sheath, which assessment finding warrant immediately interventions by the nurse? (Select all that applied.)
Unrelieved back and flank pain.
Quarter-size red drainage at site
Cool and pale left leg and foot.
Tenderness over insertion site
Left groin egg-size hematoma.
649. Which instruction is most important for the nurse to provide a client who receives a new plan of care to treat osteoporosis?
Remain upright after taking the medication.
650. A newly hired home health care nurse is planning the initial visit to an adult client who has had multiple sclerosis (MS) for the past 20 years and is currently bed-bound and is lifted by a hoist. And unlicensed caregiver provides care 8 hours/ daily, 5 days/week. During the initial visit to this client, which intervention is most important to the nurse to implement?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Determine how the client is cared for when caregiver is not present.
651. A client with urticaria due to an environmental allergies is taking diphenhydramine... Which complaint should the nurse identify to the client as a side effect of the OTC medication?
Nausea and indigestion.
Hypersalivation
Eyelid and facial twitching
Increased appetite
652. In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, The nurse assesses that the client in lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minutes. What assessment should the nurse perform next?
Note the appearance and patency of the client’s peripheral IV site.
Palpate the volume of the client’s right radial pulse
Auscultate the client’s breath sounds bilaterally.
Observe the amount and dose of morphine in the PCA pump syringe.
653. A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10), two hours ago, he received hydrocodone / acetaminophen 7.5/7.50 mg his vital signs are elevated from reading of a previous hour: temperature 97.8 F, heart rate 102 beats / minute, respiration 20 breaths/minutes. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but left is greater than right. Preoperatively, clopidrogel was prescribed for a history of previous peripheral stents. Another nurse is holding manual pressure on the femoral arterial access site which may be leaking into the abdomen. What data is needed to make this report complete?
Surgeon needs to see client immediately to evaluate the situation
654. Which instruction is most important for the nurse to provide a client who is being discharge following treatment for Guillain-Barre syndrome?
Avoid exposure to respiratory infections
Use relaxation exercises when anxious
Plan short, frequent rest periods
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Continue physical therapy at home
655. The nurse assesses a female client with obstructive sleep apnea syndrome (OSAS) who is 5 feet tall (152 cm) and weighs 155 pounds (70 kg), the client’s 24 hour diet history includes: no breakfast, cheeseburger and fries for lunch; lasagna, chocolate ice cream and a cola drink for dinner, and 2 glasses of wine in the evening before going to bed for a total caloric intake of 3500 calories. What instructions should the nurse provide? (Select all that apply)
Maintain current caloric intake
Avoid use of alcohol as a sleep aide at bedtime
Reduce intake of dairy products
Start a weight loss program
Set a goal of increasing BMI (Body Mass Index)
656. A male client with impaired renal function who takes ibuprofen daily for chronic arthritis…gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70, and his renal output is 20 ml / hour. Which intervention should the nurse include in hours?
Evaluate daily serial renal laboratory studies for progressive elevations
657. The health care provider prescribes atenolol 50 mg daily for a client with angina pectoris…to the health care provider before administering this medication?
Irregular pulse
Tachycardia
Chest pain
Urinary frequency
658. When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform?
Hold the thermometer in place.
659. An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive…medication therapy, the nurse notices the client has more energy, is giving her belongings…mood. Which intervention is best for the nurse to implement?
Ask the client if she has had any recent thoughts of harming herself
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 660. An adult female client with chronic kidney disease (CKD) asks the nurse if she can continue…Medications. Which medication provides the greatest threat to this client?
Magnesium hydroxide (Maalox)
661. The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based clean…tray to the room. The UAP rub both hands thoroughly for 2 minutes while standing at the…should the nurse take?
Explain that the hand rub can be completed in less than 2 minutes
662. An adolescent’s mother calls the clinic because the teen is having recurrent vomiting and…Combative in the last 2 days. The mother states that the teen takes vitamins, calcium, mag…With aspirin. Which nursing intervention has highest priority?
Instruct the mother to take the teen to the emergency room
663. A male Korean-American client looks away when asked by the nurse to describe his problem. What is the best initial nursing action?
Allow several minutes for the client to respond
Ask social services to find a Korean interpreter
Repeat the question slowly and distinctly
Establish direct eye contact with the client
664. An older female client tells the nurse that her muscles have gradually been getting weak…what is the best initial response by the nurse?
Ask the client to describe the changes that have occurred
665. When organizing home visits for the day, which older client should the home health nurse plan to visit first?
A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools
666. A client is admitted for type 2 diabetes mellitus (DM) and chronic Kidney disease (CKD)…which breakfast selection by the client indicates effective learning?
Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces coffee
667. A client with a postoperative wound that eviscerated yesterday has an elevated temperature…most important for the nurse to implement?
Obtain a wound swab for culture and sensitivity
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 668. The nurse is reinforcing home care instructions with a client who is being discharged following…prostate (TURP). Which intervention is most important for the nurse to include in the client…
Report fresh blood in the urine
669. The nurse provides feeding tube instructions to the wife of a client with end stage cancer. The client’s wife performs a return demonstration correctly, but begins crying and tells the nurse, “I just don’t think I can do this every day.” The nurse should direct further teaching strategies toward which learning domain?
Cognitive
Affective
Comprehension
Psychomotor
670. A male client with rheumatoid arthritis is schedule for a procedure in the morning. The…unable to complete the procedure because of early morning stiffness. Which intervention…implement?
Assign a UAP to assist the client with a warm shower early in the morning
671. The nurse is caring for a client following a myelogram. Which assessment finding should the nurse report to the healthcare provider immediately?
Complain of headaches and stiff neck
672. A woman who takes pyridostigmine for myasthenia gravis (MG) arrives at the emergency department complaining of extreme muscle weakness. Her adult daughter tells the nurse that since yesterday her mother has been unable to smile, which assessment finding warrants immediate intervention by the nurse?
Uncontrollable drooling
Inability to raise voice
Tingling of extremities
Eyelid drooling
673. A client with multiple sclerosis (MS) is admitted to the medical unit. The client reports…which action should the nurse implement to reduce the client’s risk for falls?
Schedule frequent rest periods
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Provide assistance to bedside commode
Teach to patch one eye when ambulating
674. What is the nurse’s priority goal when providing care for a 2-year-old child experiencing seizure…
Stop the seizure activity
Decrease the temperature
Manage the airway
Protect the body from injury
675. A client is complaining of intermittent, left, lower abdominal pain that began two days ago…implement the following interventions?
Correct orders: (DPIA) 1. Determine when the client had last bowel movement 2. Position client supine with knees bent 3. Inspect abdominal contour 4. Auscultate all four abdominal quadrants
676. The nurse is caring for four clients…postoperative hemoglobin of 8.7 mg/dl; client C, newly admitted with potassium…an appendectomy who has a white blood cell count of 15,000mm3. What intervention…
Determine the availability of two units of packed cells in the blood bank for client B
Increase the oxygen flow rate to 4 liters/minute per face mask for client A
Remove any foods, such as banana or orange juice, for the breakfast tray for client C
Inform client D that surgery is likely to be delayed until the infection responds to antibiotics
677. A client with a new diagnosis of Raynaud’s disease lives alone. Which instruction should the nurse include in the client’s discharged teaching plan?
Keep room temperature 80
678. Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated and his
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) bloods pressure drops to 60/40. Which intervention should the nurse implement?
Infuse a rapid IV normal saline bolus
679. A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull growing pain that is relieved when he eats. What is the best response by the nurse?
Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer
680. A mother calls the nurse to report that at 0900 she administered a PO dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine, what instruction should the nurse provide to this mother
Withhold this dose
681. When checking a third grader’s height and weight the school nurse notes that these measurements have not changed in the last year. The child is currently taking daily vitamins, albuterol, and methylphenidate for attention deficit hyperactivity disorder (ADHD). Which intervention should the nurse implement?
Refer child to the family healthcare provider
682. An adolescent receives a prescription for an injection of s-matriptan succinate 4 mg subcutaneously for a migraine headache. Using a vial labeled, 6 mg/ 0.5 ml, how many ml should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest hundredth.) 0.33 mL
Rationale: 4mg x 0.5 ml=2/6=0.33 ml
683. An unlicensed assistive personnel (UAP) informs the nurse who is giving medications that a female client is crying. The client was just informed that she has a malignant tumor. What action should the nurse implement first?
Tell the client that the nurse will be back to talk to her after medications are given
684. The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she might be getting Alzheimer’s disease. What action should the nurse take?
Explain that memory loss and confusion are common with vitamin B12 deficiency
685. While the school nurse is teaching a group of 14-year-olds, one of the participants remarks, “You are too young to be our teacher! You’re not much older than we are!” How
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) should the nurse respond?
“How old do you think I am?”
“We need to stay focused on the topic.”
“I think I am qualified to teach this group.”
“Do you think you can teach it any better?”
686. An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. What action should the nurse take first?
Begin manual ventilation immediately.
687. After diagnosis and initial treatment of a 3 year old with Cystic fibrosis, the nurse provides home care instructions to the mother, which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions?
Chest physiotherapy should be performed twice a day before a meal.
688. A middle-aged woman, diagnosed with Graves’ disease, asks the nurse about this condition. Which etiological pathology should the nurse include in the teaching plan about hyperthyroidism? (Select all that apply.)
Graves’ disease, an autoimmune condition, affects thyroid stimulating hormone receptors.
T3 and T4 hormone levels are increased
Large protruding eyeballs are a sign of hyperthyroid function
Weight gain is a common complaint in hyperthyroidism
Early treatment includes levothyroxine (Synthroid).
689. A male client who was admitted with an acute myocardial infarction receives a cardiac diet with sodium restriction and complains that his hamburger is flavorless. Which condiment should the nurse offer?
Fresh horseradish
690. While completing an admission assessment for a client with unstable angina, which closed questions should the nurse ask about the client's pain?
Does your pain occur when walking short distances?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 691. A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room?
place the id bands on the infant and mother
692. A female client with chronic urinary retention explains double voiding technique to the nurse by stating she voids partially, hold the remaining urine in her bladder for three minutes, then voids again to empty her bladder fully. How should the nurse respond?
Advise the client to empty her bladder fully when she first voids
693. A client is receiving an IV solution of nitroglycerin 100mg/500ml D5W at 10 mcg/ minute. The nurse should program the infusion pump to deliver how many ml/hour? ( Enter numeric value only) 3 ml/hour
Rationale : 0.01 x 500 x 60 / 100 = 3
694. When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first?
Massage the uterus to decrease atony
Review the hemoglobin to determine hemorrhage
Increase intravenous infusion
Check for a distended bladder
695. A-12-years old boy has a body mass index (BMI) of 28, a systolic pressure and a glycosylated hemoglobin (HBA1C) of 7.8%. Which selection indicated that his mother understands the management of his diet?
One whole-wheat bagel with cream cheese, two strips of bacon, six ounces of orange juice.
Rationale: Diet - Foods high in carbohydrates and fiber, low fat. No honey, no ham, no high sugar, no frost food, avoid all whole wheat products.
696.
Which class of drugs is the only source of a cure for septic shock?
Antiinfectives
697. A 59-year-old male client comes to the clinic and reports his concern over a lump that, “just popped up on my neck about a week ago.” In performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is not overlying tissue inflammation. What do these findings suggest?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Malignancy
Bacterial infection
Viral infection
Lymphangitis
698. A gravida 2 para 1, at 38-weeks gestation, scheduled for a repeat cesarean section in one week, is brought to the labor and delivery unit complaining of contractions every 10 minutes. While assessing the client, the client’s mothers enter the labor suite and says in a loud voice, “I’ve had 8 children and I know she’s in labor. I want her to have her cesarean section right now!” what action should the nurse take?
Request the mother to leave the room
Tell the mother to stop speaking for the client
Request security to remove her from the room
Notify the charge nurse of the situation
699. While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child’s lips and nares are dry and cracked. Which intervention should the nurse implement?
Ask the mother what she usually uses on the child’s lips and nose
Apply a petroleum jelly (Vaseline) to the child’s nose and lips
Use a topical lidocaine (Zylocaine viscous) analgesic for cracked lips
Use a water soluble lubricant on affected oral and nasal mucosa
700. The healthcare provider prescribes carboprost tromethamine (Hemabate) 250 mcg IM for a multigravida postpartum client who is experiencing heavy, bright red vaginal bleeding. Prior to administering this medication, which interventions should the RN implement?
Obtain a second IV access.
Decrease the room temperature.
Give the prescribed antiemetic.
Insert an indwelling catheter.
701. During the infusion of a second unit of packed red blood cells, the client’s temperature increases from 99 to 101.6 f. which intervention should the nurse implement?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Stop the transfusion start a saline
Observe for a maculopapular rash
Report the fever to the blood bank
Give a PRN dose of acetaminophen
702. An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms?
Destruction of joint cartilage.
703. When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past 8 hours the client’s GCS score has been 14. What does this GCS finding indicate about the client?
Neurologically stable without indications of an increased ICP
704. A 46-year-old male client who had a myocardial infarction 24-hours ago comes to the nurse’s station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?
Ineffective coping related to denial
705. In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement?
Document the extend of the bruising in the medical record
706. A client is admitted for cellulitis surrounding an insect bite on the lower, right arm and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture?
Lower the left arm below the level of the heart
707. Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the healthcare provider for evaluation of thyroid functioning?
Cold sensitivity
708. A client with hyperthyroidism is admitted to the postoperative after subtotal thyroidectomy. Which of the client’s serum laboratory values requires intervention by the nurse?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Total calcium 5.0 mg/dl
709. A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first?
Explore the client’s reasons for wanting to be discharged.
710. The nurse is assessing a primigravida a 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider?
Fetal heart rate of 200 beats/minute
711. A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnose osteoporosis. What instruction should the nurse include in the client’s teaching plan?
Take on an empty stomach with a full glass of water
712. The nurse is assessing a female client’s blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm hg and as soon as the cuff is deflated a korotkoff sound is heard. Which intervention should the nurse implement next?
Wait 1 minute and palpate the systolic pressure before auscultating again.
713. After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?
Ask the client about gastrointestinal pain
714. To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement?
Review the staff nurse job description to ensure that it is clear, accurate, and current
715. A client with pneumonia has arterial blood gases levels at: PH 7.33; PaCO2 49 mm/hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results?
Institute coughing and deep breathing protocols
716. The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and the interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, “She says it is OK.” What action should the nurse take next?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Ask for a full explanation from the interpreter of the witnessed discussion
717. While assisting a male client who has muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement?
Place a portable toilet next to the bed
718. A client with hyperthyroidism who has not been responsive to medications is admitted for evaluation. What action should the nurse implement? (Click on each chart tab for additional information. Please scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.)
Notify the healthcare provider
719. While taking vital signs, a critically ill male client grabs the nurse’s hand and ask the nurse not to leave. What action is best for the nurse to take?
Pull up a chair and sit beside the client’s bed
720. The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?
Viral meningitis whose temperature changed from 101 F to 102 F.
721. An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription?
1000, 1600, 2200, 0400
722. A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, II, aVF and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement?
Asses for contraindications for thrombolytic therapy
723. A client with Addison’s crisis is admitted for treatment with adrenal cortical supplementation. Based on the client’s admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply)
Headache and tremors
Postural hypotension
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
Pallor and diaphoresis
Irregular heart beat
724. A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client’s plan of care?
Evaluate daily blood clotting factors.
725. The nurse enters a client’s room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?
Evaluate the oxygen saturation
726. During a clinic visit, a client with a kidney transplant ask, “What will happen if chronic rejection develops?” which response is best for the nurse to provide?
Dialysis would need to be resumed if chronic rejection becomes a reality
727. The nurse enters a client’s room and observe the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first?
Place the side rails in an up position
728. A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse?
Leakage around catheter insertion site
729. A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication?
Chest pain and dysrhythmia
730. A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now they taste “bitter”. He complains that he simply has no appetite. What action should the nurse implement?
Suggest the use of alternative sources of protein such as dairy products and nuts
731. A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) should the nurse make?
Contact the healthcare provider immediately to report the laboratory value regardless of the advice
732. Which actions should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom.) 1. Place stethoscope in suprasternal area to auscultate from bronchial sounds 2. Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds 4. Document normal breath sounds and location of adventitious breath sounds 733. The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation?
Recommend weigh bearing physical activity
2. The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she might be getting Alzheimer’s disease. What action should the nurse take? Explain that memory loss and confusion are common with vitamin B12 deficiency 3. A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication? Blood pressure 90/76 mm Hg 4. During discharge teaching, an overweight client heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client’s list should the nurse encourage? (Select all that apply) A. Canned fruit in heavy syrup. B. Plain, air-popped popcorn. C. Cheddar cheese cubes. D. Natural whole almonds. E. Lightly salted potato chips
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 5. A client with Addison’s disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client’s laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications? A. Regular insulin. B. Hydrocortisone C. Broad spectrum antibiotic D. Potassium chloride 6. An adolescent, whose mother recently died, comes to the school nurse complain headache. Which statement made by the students should warrant further explanation nurse? A. ―I’ve had dreams about Mon since she died.‖ B. ―I’ve been very sad and cry a lot at night.‖ C. ―I miss Mon and would like to go see her’‖. D. ― it’s hard to concentrate on my homework‖ 7. When washing soiled hands, the nurse first wets the hands and applies soap. The nurse should complete additional actions in which sequence? (Arrange from first action on top last action on bottom.) 1. Rub hands palm to palm. 2. Interlace the fingers, 3. Dry hands with paper towel. 4. Turn off the water faucet. 8. An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding? Document the ongoing wound healing. 9. The nurse is caring for four clients who are on the rehabilitation unit, which client should the nurse assess first? A. A client with an above-the-knee amputation who is complaining of phantorn pain. B. A client who is receiving a continuous tube feeding and is now vomiting. C. A client with left hemiplegia who is scheduled for hemodialysis today. D. A client with pneumonia who is scheduled for pulmonary function studies. 10. A client’s telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression, after another minute of compression , the client’s rhythm converts to supraventricular tachycardia (SVT) on the monitor, at this point , what is the priority intervention for the nurse? A. Prepare for transcutaneous pacing B. Administer IV epinephrine per ACLS protocol. C. Give IV dose of adenosine rapidly over 1-2 seconds. D. Deliver another defibrillator shock. 19. A client with a history of using illicit drugs intravenously is admitted with Kaposi’s sarcoma. Which intervention should the nurse include in this client’s admission plan of care?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) A. Identify local support HIV support groups. B. Assess for symptoms of AIDS dementia. C. Observe for adverse drug reaction. D. Monitor for secondary infections. 20. After an elderly female client receives treatment for drug toxicity, the HCP prescribes a 24hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client’s serum creatinine is 0.3mg/dl. What action should the nurse implement? A. Initiate the urine collection as prescribed. B. Notify the HCP of the results. C. Evaluate the client’s serum BUN level. D. Assess the client for signs of hypokalemia. 21. Immediately after extubation, a client who has been mechanically ventilated is placed on a 50% non-rebreather. The client is hoarse and complaining of a sore throat. Which assessment finding should the nurse report to the healthcare provider immediately? A. Blood tinged sputum B. Expiratory wheezing C. Upper airway stridor D. Oxygen saturations 90% 22. The nurse is collecting sterile sample for culture and sensitivity from a disposable three chamber water-seal drainage system connected to a pleural chest tube. The nurse should obtain the sample from which site on the drainage system? A. Stopper port located above the water-seal level B. Plastic tubing located at the chest insertion site C. Rubberized port at the bottom of collection chamber D. Tubbing located on the top of the suction chamber 23. While the nurse is preparing a scheduled intravenous (IV) medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement? A. Apply ice first, then a warm compress to the IV site B. Discontinue the painful IV after a new IV is inserted C. Review the medical record for the date of insertion D. Document that the medication was not administered 24. During a staff meeting, a nurse verbally attacks the nurse manager conducting the meeting, stating, ―you always let your favorites have holidays off give then easier assignments. You are unfair and prejudiced‖ how should the nurse-manager respond? A. I would prefer to discuss this with you privately. B. Give me specific examples to support your statements. C. Does anyone else on the staff fell the same way D. Your remarks are not true and are very unkind
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 25. An adult is admitted to the emergency department following ingestion of a bottle of antidepressants secondary to chronic paint. A nasogastric tube and a left subclavian venous catheter are placed. The nurse auscultates audible breath sounds on the right side, faint sounds procedure should the nurse prepare for first? A. Insertion of a left- sided chest tube. B. Placement of an endotracheal tube. C. Retraction of the nasogastric tube D. Setup of patient- controlled analgesia 26. A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? Abnormal responses for cranial nerves I and II Persistent coughing while drinking Unilateral facial drooping Inappropriate or exaggerated mood swings 27. A male client is admitted with a severe asthma attack. For the last 3 hours he has experienced increased shortness of breath. His arterial blood gas results are: pH 7.22 PaCO2 55 mmHg; HCO3 25 mEq/L or mmol/L (SI). Which intervention should the nurse implement? A. Space care to provide periods of rest B. Instruct client to purse lip breathe C. Administer PRN dose of albuterol D. Position client for maximum comfort 28. A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first? A. Enalapril B. Furosemide C. Acetaminophen D. Promethazine 29. When entering a client’s room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement? A. Ignore the behavior and hang the IV antibiotic B. tell the client to stop the inappropriate behavior C. Leave the room and close the door quietly D. Complete an unusual occurrence report 30. The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply) Ease the client to the floor Loosen restrictive clothing
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) Note the duration of the seizure 40. A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity? Tachycarcia Dyspnea Vomiting Muscle cramps 41. An antacid is prescribed for a client with gastroesophageal (GERD). The client asks the nurse, ―How does this help my GERD?‖ What is the best response by the nurse? A. This medication will coat the lining of your esophagus B. Antacids will neutralize the acid in your stomach C. It will improve the emptying of food through your stomach D. antacids decrease the production of gastric secretions 42. The nurse suspect may be hemorrhaging internally. Which findings of an orthostatic test may indicate to the nurse of major bleed? A decrease in the systolic b/p of 10mm/hg with a corresponding increase of heart rate of 20. 43. A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client’s discharge plan? A. Avoid exposure to large crowds B. Do not take any over-the-counter medications C. Call the crisis hot line if feeling lonely D. Eat a high carbohydrate, low fat, low protein diet 44. A client arrives in the emergency center with a blood alcohol level of 500 mg/dl. When transferred to the observation unit, the client becomes demanding, aggressive, and shouts at the staff. Which assessments finding is most important for the nurse to identify in the first 24 hours? A. Decreased appetite B. Nausea and elevated blood pressure C. Difficulty walking D. Agitation and threats to harms staff 45. A male client who had a small bowel resection acquired methicillin- resistant Staphylococcus aureus (MRSA) while hospitalized. He was treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention? Maintain contact transmission precautions 46. The nurse applies a blood pressure cuff around a client’s left thigh. To measure the client’s blood pressure, where should the diaphragm of the stethoscope be placed? (Mark the loication on one of the images.) ―On left thigh with arrow pointing to inner thigh‖
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
47. To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client’s discharge plan? (Select all that apply). A. Practice relaxation exercises B. Limit fluids to avoid bladder distention C. Space activities to allow for rest periods D. Avoid persons with infections E. Take warm baths before starting exercise 48. A preoperative client states he is not allergic to any medications. What is the most important nursing action for the nurse to implement next? A. Record ―no known drug allergies‖ on preoperative checklist B. Assess client’s allergies to non-drug substances C. Assess client’s knowledge of an allergy response D. Flag ―no known drug allergies‖ on the front of the chart 49. During a visit to the planned parenthood clinic, a young woman tells the nurse that she is going to discontinue taking the oral contraceptives she has taken for three years because she wants to get pregnant. History indicates that her grandfather has adult onset diabetes and that she was treated for chlamydia six months ago, which factor in this client’s history poses the greatest risk for this woman’s pregnancy? A. Family history of adult onset diabetes. B. Treatment for chlamydia in the past year C. Client’s age and previous sexual behavior D. Three year history of taking oral contraceptives 50. When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack foods should the nurse encourage the client to eat? (Select all that apply). A. Fresh turkey slices and berries B. Fresh vegetables with mayonnaise dip C. Soda crackers and peanut butter D. Chicken bouillon soup and toast
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) E. raw unsalted almonds and apples 51. A mother brings her 3-week-old son to the clinic because he is vomiting ―all the time.‖ In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. What intervention should the nurse implement first? A. Give the infant 5% dextrose in water orally B. Insert a nasogastric tube for feeding C. Initiate a prescribed IV for parental fluid D. Feed the infant 3 ounces of Isomil 52. An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gases indicate hypoxia. Which intervention is most important for the nurse to implement? A. Prepare for emergent oral intubation B. Offer sips of favorite beverages C. Clarify end of life desires D. Initiate comfort measures 53. Which needle should the nurse use to administer intravenous fluids (IV) via a client’s implanted port?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
60. The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse? A. A 12-year-old with complaints of neck and lower back discomfort B. An 11-year-old with a headache, nausea, and projectile vomiting C. A 6-year-old with multiple superficial lacerations of all ectremities D. An 8-year-old with a full leg air splint for a possible broken tibia 61. An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? A. Ask the UAP to take the blood pressure in the other arm B. Tell the UAP to use a different sphygmomanometer. C. Review the client’s serum calcium level D. Administer PRN antianxiety medication. 63. The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement? A. Inquire about food allergies and food likes and dislikes B. Talk directly to the adolescent while providing care C. Initiate open communication with the teen’s parents D. Monitor vital signs and neuro status every 2 hours 64. Following an open reduction of the tibia, the nurse notes bleeding on the client’s cast. Which action should the nurse implement? A. No action is required since postoperative bleeding can be expected B. Lower the client’s head while assessing for symptoms of shock C. Call the health care provider and prepare to take the client back to the operating room D. Outline the area with ink and check it every 15 minutes to see if the area has increased 65. While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) A. Blood pressure fluctuations means that the condition has become chronic B. Elevated blood pressure must be anticipated and identified quickly C. Hypotension leading to sudden shock can develop at any time D. Sodium intake with meals and snacks affects the blood pressure 66. The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which instructions should the nurse provide the mother? (Select all that apply) Close car windows and use air conditioner Avoid sudden changes in temperature Keep away from pets with long hair Stay indoors when grass is being cut 67. Which client should the charge nurse on the oncology unit assign to an RN, rather than a practical nurse (PN)? An elderly female client with cancer whose children who are trying to decide whether to change to palliative care measures or continue disease control 68. An elderly male client is admitted to the urology unit with acute renal failure due to a postrenal obstruction. Which questions best assists the nurse in obtaining relevant historical data? A. ―Have you had a heart attack in the last 6 months‖ B. ―Have you had any difficulty in starting your urinary stream‖ C. ―Have you taken any antibiotics recently‖ D. ―Have you received any blood products in the last year‖ 69. A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child? Sitting up and leaning forward
70. A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen? A. Bone marrow transplantation B. Blood transfusion C. Chemotherapy
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) D. Immunosuppressive therapy 71. For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action? Tented skin turgor 72. An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. What action should the nurse take first? Begin manual ventilation immediately. 73. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? Obtain a clean catch mid-stream specimen 73. A client’s subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next? Collect a clean-catch specimen 74. A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply). A. A bedside commode is positioned near the bed B. A saline lock is present in the right forearm C. A full pitcher of water is on the bedside table D. The client is lying in a supine position in bed E. A low sodium diet tray was brought to the room 75. A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a ―Do Not Resuscitate‖ prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously schedules. What action should the nurse take? A. Advise the UAP to resume positioning the client on schedule B. Encourage the UAP to provide comfort care measures only C. Assume total care of the client to monitor neurologic function D. Assign a practical nurse to assist the UAP in turning the client 76. The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain? A. Degree of skin elasticity B. Appearance of wound C. Bilateral pedal pulse force D. Onset of any bleeding
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 77. The HCP prescribes methotrexate 7.5 mg PO weekly, in 3 divides doses for a child with rheumatoid arthritis whose body surface area (BSA) is 0.6 m2. The therapeutic dosage of methotrexate PO is 5 to 15 mg/m2/week. How many mg should the nurse administer in each of the three doses given weekly? (Enter the numeric value only. If round is required, round to the nearest tenth.) 1.5 78. An alert older client with diabetes mellitus type 1 is admitted with a serum glucose of 420 mg/dl (23.31 mmol/L (SI)). As the nurse administers 10 units of regular insulin intravenous (IV), the client immediately begins to vomit. What action should the nurse implement first? Turn the client to a lateral position 79. A client is admitted to the surgical unit with symptoms of a possible intestinal obstruction. When preparing to insert a nasogastric (NG) tube, which intervention should the nurse implement? A. Elevate the head of the bed 60 to 90 degrees B. Measure from corner of mouth to angle of jaw C. Administer a PRN analgesic D. Assess for a gag reflex 80. A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? Inform her that some antianxiety medications are safe to take while breastfeeding 81. At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, ―I just know I can’t handle all the pain.‖ What is the priority nursing diagnosis for this client? Anxiety 82. In early septic shock states, what is the primary cause of hypotension? A. Cardiac failure B. A vagal response C. Peripheral vasoconstriction D. Peripheral vasodilation 83. The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse has gathered supplies, including intravenous catheters, an intravenous insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. What action should the charge nurse take? A. Plan to observe the secured IV site after the insertion procedure B. Confirm that the nurse has gathered the necessary supplies C. Remind the nurse to tape the gauze dressing securely in place D. Instruct the nurse to use a transparent dressing over the site
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 84. An adult client comes to the clinic and reports his concern over a lump that ―just popped up on my neck about a week ago.‖ In performing an examination of the lump, the nurse palpates a large, non-tender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these finding suggest? A. Bacterial infection B. Lymphangitis C. Malignancy D. Viral infection 85. The nurse is preparing to administer an IV dose of ciprofloxacin to a client with urinary tract infection. Which client data requires the most immediate intervention by the nurse? A. Urine culture positive for MRSA B. Serum sodium of 145 mEq/L (145 mmol/L SI) C. Serum creatinine of 4.5 mg/dl (398 mcmol/L SI) D. White blood cell count of of 12,000 mm3 (12 x 109/L SI) 86. The unit clerk reports to the charge nurse that a healthcare provider has written several prescriptions that are illegible and it appears the healthcare provider used several unapproved abbreviations in the prescriptions. What actions should the charge nurse take? A. Complete and file an incident (variance) report B. Call the healthcare provider who wrote the prescription C. Contact the healthcare provider review board for instructions D. Report the situation to the house supervisor 93. A confused, older client with Alzheimer’s disease becomes incontinent of urine when attempting to find the bathroom. Which action should the nurse implement? A. Instruct the client to use the call button when a bedpan is needed B. Apply adult diapers after each attempt to void C. Check residual urine volume using an indwelling urinary catheter D. Assist the client’s to a bedside commode every two hours 94. The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client’s medical history? Frequency of laxative use for chronic constipation 95. The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply.) A. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). B. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty C. Perform daily surgical dressing change for a client who had an abdominal hysterectomy D. Initiate patient controlled analgesia (PCA) pumps for two clients immediately postoperative E. Start the second blood transfusion for a client twelve hours following a below knee amputation
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 96. In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider? A. Watery diarrhea B. Yellow-tinged sputum C. Increased fatigue D. Nausea and headache 98. The nurse is preparing to mix two medications from two different multidose vials, A and B. In which order should these actions be implemented when drawing the solutions from the vials? (Arrange from first on top to last on the bottom) Verify the drug and dose with the label on the vial Inject the volume of air to be aspirated from each vial Aspirate the desired volume from vial A Aspirate the desired volume from vial B 104. An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping, and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal? A. Bring the client to the team meeting to discuss the treatment plan B. Ask the client to write feeling in a journal and then review it together C. Explain the purpose of each medication the client is currently taking D. Play a board game with the client and begin taking about stressors 105. An adult male with schizophrenia who has been noncompliant in taking oral antipsychotic medications refuses a prescribed IM medication. Which action should the nurse take? A. Notify the healthcare provider of the client’s refusal B. Administer an oral PRN medication for agitation C. Ask for staff assistance with administering the injection D. explain that oral medications will no longer be required 106. An older male client with a history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first? A. Record pain evaluation B. Assess blood glucose C. Identify pills in the bag D. Obtain a medical history 107. A male client with an antisocial personality disorder is admitted to an in-patient mental health unit for multiple substance dependency. When providing a history, the client justifies to the nurse his use of illicit drugs. Based on this pattern of behavior this client’s history is most likely to include which finding? A. Phobias and panic attacks when confronted by authority figures. B. Suicidal ideations and multiple attempts/ C. Multiple convictions for misdemeanors and class B felonies.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) D. Delusions of grandiosity and persecution 108. An adult male who fell from a roof and fractures his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse? A. Onset of mild confusion B. Pain score 8 out of 10 C. Pale, diaphoretic skin D. Weak palpable distal pulses 109. A client who has a suspected brain tumor is schedules for a computed (CT) scan. When preparing the client for the client for the CT scan, which intervention should the nurse implement? A. Determine if the client has had a knee or hip replacement B. Immobilize the client’s neck before moving onto stretcher C. Give an antiemetic to control nausea D. Obtain the client’s food allergy history 110. A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever. Which instructions should the nurse give to this client? A. Remain on clear liquids until the vomiting subsides B. Come to the clinic to be seen by a healthcare provider C. Make an appointment at the clinic if a fever occurs D. Take nothing by mouth until there is no more nausea 111. The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant’s heart rate drops to 60 beats / minute. Which action should the nurse take? A. Continue the insertion since this is a typical response B. pause and monitor for a continues drop of the heart rate C. Insert the feeding tube into the infant’s nasal passage D. Postpone the feeding until the infant’s vital signs and stable An infant is receiving gavage feedings via nasogastric tube. At the beginning of the feeding, the infant’s heart rate drops to 80 beats / minute. What action should the nurse take? Slow the feeding and monitor the infant’s response. 112. A male client is admitted with a bowel obstruction and intractable vomiting for the last several hours despite the use of antiemetics. Which intervention should the nurse implement first? (Please scroll and view each tab’s information in the client’s medical record before selecting the answer.)
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
A. Infuse 0.9 % sodium chloride 500 ml bolus B. Insert nasogastric tube to intermittent suction. C. Maintain head of bed at 45 degrees D. Document strict intake and output 113. While removing staples from a male client’s postoperative wound site, the nurse observes that the client’s eyes are closed and his face and hands are clenched. The client states, ―I just hate having staples removed.‖ After acknowledging the client’s anxiety, what action should the nurse implement? Attempt to distract the client with general conversation 114. A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elev ated blood pressure. Which intervention should the nurse implement first? A. Ensure client takes a diuretic q AM B. Obtain serum creatinine levels daily C. Measure ankle circumference D. Monitor daily sodium intake 115. The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation? A. Determine the presence of hematemesis as the UAP irrigates the NGT B. Instruct the UAP to bring an antiemetic to the nurse at the bedside C. Assess the appearance of the emesis while the UAP checks bowel sounds D. Direct the UAP to measure the emesis while the nurse irrigates the NGT 116. A preschooler with constipation needs to increase fiber intake. Which snack suggestion should the nurse provide? A. soft pretzels B. fruit-flavored yogurt C. oatmeal cookies D. low fat cheese sticks
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 117. The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? Instruct the mother to change the child’s diaper more often. Encourage the mother to apply lotion with each diaper charge Tell the mother to cleanse with soap and water at each diaper change Ask the mother to decrease the infant’s intake of fruits for 24 hours. 118. After multiple attempts to stop drinking, an adult male is admitted to the medical intensive care unit (MICU) with delirium tremens. He is tachycardic, diaphoretic, restless, and disoriented. Which finding indicates a life- threatening condition? A.CIWA-Ar for alcohol withdrawal score of 30 A. Acute onset of unrelenting chest pain C. Widening QRS complexes and flat waves D. Intense tremor and involuntary muscle activity 125. The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first? A. A client with congestive heart failure who reports a 3 pound weight gain in the last two days B. An immobile client with a stage 3 pressure ulcer on the coccyx who is having low back pain C. A client diagnosed with chronic obstructive pulmonary disease (COPD) who is short of breath D. A terminally ill older adult who has refused to eat or drink anything for the last 48 hours 126. A female client is admitted for diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most import for successful adherence to the diabetic diet? A. Knows that insulin must be given 30 min before eating B. Frequently eats fruits and vegetables at meals and between meals/ C. Has someone available who can prepare and oversee the diet D. Demonstrates willingness to adhere to the diet consistently 127. A client currently receiving an infusion labeled Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 mL at 14 mL/hour. A prescription is received to change the rate of the infusion to 900 units of Heparin per hour. The nurse should set the infusion pump to deliver how many mL/hour? (Enter numeric value only). 700 Rationale: D/H x Q = 25000 / 500 x 14 = 700 128. Oxygen at 5l/min per nasal cannula is being administered to a 10 year old child with pneumonia. When planning care for this child, what principle of oxygen administration should the nurse consider? A. Taking a sedative at bedtime slows respiratory rate, which decreases oxygen? B. Avoid administration of oxygen at high levels for extendedperiods. C. Increase oxygen rate during sleep to compensate for slower respiratory rate. D. Oxygen is less toxic when it is humidified with a hydration source.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 129. The nurse is caring for a client with acute kidney injury (AKI) secondary to gentamicin therapy the client’s serum blood potassium is elevated, which finding requires immediate action by the nurse? A. Tall peak T waves on the cardiac monitor B. Peripheral pitting edema at 2 + indentation C. Serum creatinine above 0.5 mg/dl or 44.2 micro-mmol/dl D. Anuria for the last 12 hours. 130. A client presents to the labor and delivery unit, screaming ―THE BABY IS COMING‖ which action should the nurse implement first. Observe the perineum VIDEO 131. During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class, as seen in the video. After the demonstration, the supervising nurse expresses concern that the demonstrated procedure increased the client’s risk for which problem? A. Infection B. Ineffective airway clearance C. Altered comfort D. Impaired gas exchange 132. One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement? Observe for unilateral swelling 133. A male client with diabetes mellitus type 2, who is taking pioglitazone PO daily, reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish cast to his skin. What instructions should the nurse provide? A. ―You have become dehydrated from the nausea. You will need to rest and increase fluid intake‖ B. ―you need to seek immediate medical assistance to evaluate the cause of these symptoms‖ C. A urine specimen will be needed to determine what kind of infection you have developed‖ D. use insulin per sliding scale until the nausea resolves, and then resume your oral medication‖ 134. A male client with ulcerative colitis received a prescription for a corticosteroid last month, but because of the side effect he stopped taking the medication 6 year ago. Which finding warrants immediate intervention by the nurse? A. Hypotension and fever B. Anxiety and restlessness. C. Fluid retention D. Increased blood glucose. 138. A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, an exhibiting signs of restlessness. Which action should the nurse take fist? Administer PRN dose of lorazepam
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) Auscultate bilateral breath sounds Check urinary catheter for obstruction Review the heart rhythms on cardiac monitor. 139. A young adult female client with recurrent pelvic pain for 3 year returns to the clinic for relief of severe dysmenorrhea. The nurse reviews her medical record which indicates that the client has endometriosis. Based on this finding, what information should the nurse provide this client? A) Oral contraceptives increase the symptoms of endometriosis. B) The symptoms of endometriosis can increase with menopause. C) An option to diagnose disease extent and provide therapeutic treatment is laparoscopy. D) Infertile is successfully treated with removal of intra-abdominal endometrial lesions. 140. A 75-year-old female client is admitted to the orthopedic unit following an open reduction and internal fixation of a hip fracture. On the second postoperative day, the client becomes confused and repeatedly asks the nurse she is. What information for the nurse to obtain? A. Use of sleeping medications. B. History of alcohol use, C. Use of antianxiety medications, D. History of this behavior. 141. To reduce the risk of being named in malpractice lawsuit, which action is most important for the nurse to take? A. Establish a trusting nurse-client relationship. B. Complete an incident report following a client injury. C. Maintain current professional malpractice insurance, D. Adhere consistently to standards of care. 142. A client with multiple sclerosis is receiving beta-1b interferon every other day. To assess for possible bone marrow suppression caused by the medication, which serum laboratory test findings should the nurse monitor? (Select all that apply) A. Platelet count B. Red blood cell count (RBC) C. White blood cell count (WBC). D. Albumin and protein E. Sodium and potassium 143. Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity? Distal pulse intensity VIDEO 144. The nurse is auscultating a client’s lung sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.) https://www.youtube.com/watch?v=VGDdqtIhUdA
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) High pitched or fine crackles. High pitched wheeze Rhonchi Stridor 151. The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?
Answer:
152. The nurse is assessing and elderly bedridden client. Which finding indicates that the turning and positioning schedule is effective in protecting the client’s skin? A. Reddened skin areas disappear within 15 minutes of being turned and positioned. B. No complaints of pressure or pain are verbalized by the client after being turned C. Only small areas of redness remain longer than 30 min after the client is turned. D. The client verbalizes feeling better after being turned and positioned 153. A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess effectiveness of the fluid bolus? A. Mean arterial pressure (MAP) B. White blood cell count C. Blood culture D. Oxygen saturation
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 154. A 17-year –old male is brought to the emergency department by his parents because he has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first? A. Obtain a chest X-ray per protocol. B. Place a mask on the client’s face. C. Assess the client’s temperature. D. Determine the client’s blood pressure 155. An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client’s plan of care? (Select all that apply) A. Teach client to use incentive spirometer q2 hours while awake. B. Remove urinary catheter as soon as possible and encourage voiding. C. Maintain sequential compression devices while in bed. D. Administer low molecular weight heparin as prescribed E. Assess pain level and medicate PRN as prescribed. 156. A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take? Ask a chemotherapy-certified nurse to administer the Zofran Administer the ondasentron (Zofran) after flushing the saline lock with saline Hold the scheduled dose of Zofran until the client awakens Awaken the client to assess the need for administration of the Zofran. 158. The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately? Elevate the presenting part off the cord. 159. While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first? Inquire about an electric bed for the client’s home use Submit a referral for an evaluation by a physical therapist. Explain the usual progression of osteoarthritis and HF Request social services to review the client’s resources. 160. A client is admitted to a mental health unit after attempting suicide by taking a handful of medications. In developing a plan of care for this client, which goal has the highest priority? B. Signs a no-self-harm contract. B. Sleep at least 6 hours nightly. C. Attends group therapy every day D. Verbalizes a positive self-image.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) The nurse is ready to insert an indwelling urinary catheter as seen in the picture. At this point in the procedure, what actions should the nurse take before inserting the catheter? (Select all that apply)
A. Ask the client to bear down as if voiding to relax the sphincter B. Complete perianal care with soap and water C. Gently palpate the client’s bladder for distention D. Hold the catheter 3 – 4 inches (7.5 – 10 cm) from its tip E. Secure the urinary drainage bag to the bed frame
HESI V1 2015: 1. An elderly client tells the nurse that itching and excessive tearing caused by severe eye dryness has become increasingly bothersome. The client does not suffer from external eye disease, rhinitis, or hay fever, but does take several medications. Which medications are likely to have produced this client’s problem? Antihypertensive and Anticholinergic 2. A 12-year old child with an acute episode of asthma receives a prescription for albuterol (Ventolin) via nebulization to be followed by pirbuterol (Maxair) Autoinhaler. Which assessment finding should the nurse report to the healthcare provider before administering Maxair? Palpitations and blood pressure changes 3. A client with draining skin lesions of the lower extremity is admitted with possible MRSA. Which nursing interventions should the nurse include in the plan of care? Select all that apply: Institute contact precautions for staff and visitors. Send wound exudate for culture & sensitivity. Recommend all family members be screened for MRSA. 4. The nurse is called to the school soccer field because a child has a nose bleed (Epistaxis). In what position should the nurse place the child? Sitting up & lean forward.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 5. In providing care for a client after gastric endoscopy, which commonly occurring problem should the nurse include interventions for in the post-procedure plan of care? Sore throat 6. The family of a client who just died arrives on the nursing unit after receiving telephone notification of the death. Several family members state they would like to view the body. How should the nurse respond? Offer to go with the family members to view the body. 7. A child who has ADHD receives a prescription for amphetamine salts (Adderall). Which instructions is most important for the nurse to provide the parents? Check the pulse rate each day. 8. Picture of a Suction Chamber: The prescribed amount is accurately read at 20cm water level. 9. Prior to a schedule full body MRI, a male client reports that he has metal tooth fillings. What interventions should the nurse implement first? Consult with the radiologist. 10. After applying an alcohol-based hand rub to the palms of the hand and rubbing the palms together, what action should the nurse take next? Place one hand on top of the other and interlace the fingers. 11. A client who is admitted with acute coronary syndrome (ACS) receives eptifibate (Integrillin), a glycoprotein (GB) IIB IIIA inhibitor. Which assessment finding places the client for greatest risk? Unresponsive to painful stimuli 12. The nurse working on a mental health unit is prioritizing nursing care activities because of staff shortage. One PN is on the unit with the nurse, and another RN is expected to arrive within two hours. Clients need to be awakened and morning medications need to be prepared. Which plan is best for the nurse to implement? Ask the PN to administer medications as clients are awakened so both nurses can are available. 13. The nurse is caring for a client immediately after inserting a PICC line. Suddenly, the client becomes anxious & tachycardic, and loud churning is heard over the pericardium upon auscultation. What action should the nurse take first? Place client in Trendelenburg position on the left side. 14. The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply: Restlessness, Clenched Fist, Increased pulse rate, Increased respiratory rate. 15. An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction & lens implantation. Which intervention is most important for the nurse to implement to ensure the client's compliance with self care? Have the client vocalize the instructions provided. 16. An 18-year-old female client is seen at the health department for TX of condylomata acuminata (perineal warts) caused by the human Papillomavirus (HPV). Which information should the nurse implement? Reinforce the importance of annual Papanicolau (PAP) smears. 17. Ten years after a female client was DX with multiple sclerosis (MS), she is admitted to the community palliative care unit. Which intervention is most
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) important for the nurse to include in the client's plan of care? Medicate as needed for pain & anxiety. 18. A mother brings her 7-year-old son to the pediatric clinic for a tetanus booster. The nurse assesses the child's growth & determines that he gained 4.9 pounds & has inches in the last year. Based on this assessment finding, what action should the nurse take? Document the child's growth and development as within the expected ranges. 19. A client is admitted with a DX of TB. Which infection control measures should the nurse implement? Negative pressure environment 20. What is the nurse's priority goal when providing care for a 2-year-old child with a febrile seizure? Manage the airway. 21. A newly hired home health care nurse is planning the initial visit to an adult client who has multiple sclerosis (MS) for the past 20 years and is currently bed-bound & lifted by a hoist. An unlicensed caregiver provides care 8hours/daily, 5 days/week. During the initial visit to the client, which intervention is most important for the nurse to implement? Determine how the client is cared for when caregiver is not present. 22. A young adult hit with a baseball bat on the left temporal area of the skull is conscious when admitted to the ED, & is transferred to the Neurology Unit to be monitored for SX of closed head injury. Which assessment finding is indicative of a developing Epidural Hematoma? Altered consciousness within the first 24 hours after injury. 23. During a home visit, the husband of reports that his wife often gasps & chokes while sleeping & seems to have frequent pauses in her breathing . The wife does not remember these episodes but does report frequent daytime fatigue. What action should the nurse implement? Refer the wife to a healthcare provider for evaluation of sleep apnea. 24. Which client is most likely to benefit from of sequential compression devices on both legs? A one-day postoperative client who requires five days of bed rest. 25. After a motor vehicle collision, a 4-year-old boy his mother died in the accident. The child is crying and tells his father, "When mommy comes back, I promise to be . Which guidance should the nurse provide this father? Repeat that his mother cannot come back. 26. The nurse is caring for a client who has suffered multiple injuries after being physically abused. Following the administration of Opioids for pain TX, which assessment findings requires immediate action by the nurse? Difficult arousing the patient. 27. A resident of a long-term care facility, who dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils then refuses to eat. What action should the nurse implement? Encourage the client to eat finger foods. 28. While cleaning a client's postoperative wound by granulation, the nurse observes a 3cm area of eschar. What information should the nurse tell the client ? Removal of the leatherly tissue promotes wound healing.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 29. The public health nurse, who is instructing Scouts about methods to prevent Lyme disease, should teach the Scouts that which action is best to use when trying disease? Spray insect repellent on skin and clothes. 30. Which location should the nurse choose as the a screening program for hypothyroidism? A business and professional women's group. 31. The nurse has received funding design a culturally-competent health promotion project for African-American women who are at risk for developing breast CA. Which is most important in developing this program? Participation of community leaders in planning the program. 32. A 13-year-old girl, diagnosed with diabetes at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is mostly likely causing ? Has had a cold and ear infection for the past two days. 33. The parents of a child with cystic fibrosis both carriers of this genetic disorder. What action should the nurse take? Advise the parents to seek genetic counseling. 34. In completing the TX plan for an 11-year-old has bipolar disorder, the nurse plans outcomes for the nursing DX, "Risk for violence towards peers related to . Which outcomes is most important? Tells staff when thoughts of harming others occur. 35. A female client with pancreatic CA is NPO for implantation of venous access device (Port-A-Cath) under conscious sedation. Suddenly, the client becomes unresponsive & her skin is cool & clammy. Her VS are: B/P: 108/70, Pulse rate: 96 beats/minute, respiratory rate: 15. Which are in her baseline VS. What intervention should the outpatient surgery nurse implement first? Obtain a finger stick blood glucose. 36. The mental health nurse is leading a group about relaxation and explains the benefits of deep breathing for relaxation. As a female client begins to explain how she uses yoga to relax, another client interrupts and asks, "What's yoga?" What is the nurse's best response? "Wait, let her finish talking." 37. A healthcare provider continuously dismisses the nursing care suggestions made by staff nurses. As a result, the staff nurses avoid dealing with the healthcare provider. What action should the nurse-manager implement? Plan an interdisciplinary staff meeting to develop strategies to enhance client care. 38. The nurse is providing intermittent gavage feedings for 33-gestational age newborn. The nurse positions the newborn in a right side-lying position with the head slightly elevated and passes the feeding tube through the mouth. Prior to administering the bolus feeding, it is most important for the nurse to obtain which assessment? Volume of gastric residual. 39. The nurse is caring for a client who had transurethral resection of the prostate yesterday . Which nursing task can be safely delegated to the UAP? Provide daily care for the indwelling urinary catheter. 40. When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTR's)? If the client has an elevated blood pressure. 41. A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy tea-colored urine. The parent's state that their son had a sore throat 2 weeks earlier, but it has resolved.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) After assessing the child's VS & weight, what intervention should the nurse implement next? Collect a urine sample for routine urinalysis. 42. A 2-month-old infant is brought to the clinic for routine immunizations? Administer oral rotavirus vaccine (RV), polio vaccine (IPV), pertussis (DTaP), hepatitis B (HB), H. Influenza type B (HIB), & pneumococcal (PCV) vaccines IM in the vastus lateralis. 43. Before assisting the client with a morning shower, the UAP reports that a client is feeling dizzy. The client's VS are: Temp: 98.9, P: 78 beats per min, R: 16 breaths/min, & B/P: 84/60 mm Hg. What action is best for the nurse to take? Direct the UAP to give the client a bed bath. 44. What information should the nurse include in the teaching for a client DX with GERD? Minimize SX by wearing loose, comfortable clothing. 45. A male client is returned to the surgical unit following a nephrectomy and is medicated with morphine sulfate 4 mg IV. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which interventions is most important for the nurse to include in this clients plan of care? Monitor urine output hourly. 46. A client with rapid respirations and audible rhonchi is admitted to the ICU because of pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based is initiated. Which intervention is most important for the nurse to include in this client's plan of care? Evaluate daily blood clotting factors. 47. The inhaler metaproterenol (Alupent), is prescribed for the client with reactive airway disease. Which behavior indicates to the nurse that the client understands the teaching concerning this medication? At the first of an asthma attack the client uses the Alupent inhaler. 48. After repositioning an immobile client, the nurse an area of hyperemia. To assess for blanching, what action should the nurse take? Apply light pressure over the area. 49. While removing an IV infusion from the hand of a client who has AIDS, the nurse is struck with the needle. After washing the puncture site with soap & water, which action should the nurse take? Notify the employee health nurse. 50. When the charge nurse assigns a PN to care for three clients who require contact precautions, the PN state, "I am not taking three isolation patient's. I refuse to gown and glove over and over. I will never get anything done!" What action should the charge nurse take? Reassign the client population and divide the isolation clients among the staff. 51. The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection? Moderate amount of foul-smelling lochia. 52. An adult male reports feeling weak, tired, and irritable. He also reports that he is having difficulty sleeping because of suicidal thoughts. The health care provider prescribes tricylic antidepressant, amitriptyline. Which instructions should the nurse include in this client's teaching plan? (select all that apply): Avoid taking over-the-counter drugs such as St. John's Wart. Do not expect relief of SX for four weeks after starting the medication. 53. The nurse is panning care for a client who has a fourth degree midline laceration that occurred during vaginal delivery of an 8-pound 10-ounce infant. What
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) intervention has the priority for this client? Administer prescribed stool softener. 54. When checking a third-grader's height & weight. The school nurse notes that these measurements have not changed in the last year. The child is currently taking daily vitamins, albuterol, & methylpenidate (Concerta) for ADHD. Which intervention should the nurse implement? Refer child to the family healthcare provider. 55. A client is receiving 0.9% NS solution at a rate of 50ml/hr. The nurse administers 100ml of intermittent IVPB medication concurrently with the IV solution at 0800 & 1200. How many ml of IV fluid intake should the nurse record in the client's medical record for the 0700-1500 shift? 600 56. When discontinuing a client's IV line, the nurse holds prolonged pressure at the site. This action is based on the knowledge that the client is receiving which medication? Clopidogrel bisulfate (Plavix) 57. On a busy day, one hour after the shift report is completed, the charge nurse learns that a female staff nurse who lives one hour away from the hospital forgot her prescription eye glasses at home. What action should the charge nurse take? Ask the nurse to return home and get her prescription eyeglasses for work. 58. Which instructions should the nurse provide to the client who is complaining of heartburn? Eat small meals throughout the day to avoid a full stomach. 59. A G:2 P:1, at 38-weeks of gestation is a repeat c/s in one week , is brought to the L&D unit c/o CTX. While assessing the client, the client's mother enters the L&D suite and says in a loud voice. "I've had 8 children, I think she's in labor. I was her to have a C/S right now!" What action should the nurse take? Request that the mother leave the room. 60. A female client with a HX of HF the clinic after she describes a very long trip. Following the initial physical assessment and chart review which action should the nurse implement? Administer the prescribed diuretics. 61. The plan of care for a client who has recently DX with breast CA includes the nursing's DX, Anxiety related to the threat of secondary to the CA DX. The expected outcome should the nurse identify for the client? Uses coping methods mechanism effectively. 62. A client receiving chemo has severe neutropenia which snack is best for the nurse to recommend to the client? Baked apple topped with raisins 63. A client with cirrhosis & hepatic encephalopathy has extensive ascites resulting from portal HTN. What finding provides the nurse with an early indication that the client is at risk for threatening complication? Hematemesis & melena 64. A client is admitted with possible urosepsis. What intervention should the nurse perform as soon as possible? Obtain a urine specimen with culture & sensitivity 65. Which equipment should the nurse use to administer a liquid iron preparation to an infant with iron deficiency anemia? A medicine dropper 66. A client who is recently DX with type 2 DM ask the nurse how this type of diabetes leads to high blood sugar. What Pathophysiology mechanism should the nurse explain about the occurrence of hyperglycemia in those who have type 2 DM? The body cells develop resistance to the action of insulin.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 67. A 20-year-old female who is 5'6" tall admitted to mental health weighing 60 lbs, C/O palpitations & states, "I just wish my heart will stop beating all together." Which response by the nurse is best to respond? Have you had any thoughts of harming yourself? 68. After receiving the morning report at 7o'clock on a PP unit. Which client should the nurse assess 1st? 23 hour PP & C/O Epigastric pain 69. Picture of a restrained bed: Assess the client's radial pulse, raise upper side rail of the bed, document use of restraints. 70. A client has a RX for Lorazepam (Ativan) 2mg for alcohol withdrawal SX. Which finding indicates that the nurse should medicate the patient? B/P of 149/101 71. Calculations Questions: The nurse notes the client receiving heparin infusion labeled, Heparin Na 25,000 Units in 5% Dextrose injection 500 ml @ 50ml/hr. What does of Heparin is the client receiving per hour? 2,500
72. A primigravida client is 36 weeks gestation is admitted to L&D unit because her membranes ruptured 30minutes ago. Initial assessment indicates 2cm dilation, 50% effaced, -2 station, vertex presentation greenish color fluid, and contractions occurring 3-5 minutes with a low FHR after the last contraction peaks: Choices are: A. Administer O2, B. Notify Physician, C. Apply Fetal Monitor, D. Use of vibrate acoustic stimulation 73. After receiving a pre-operative sedative a female client tells the nurse she needs to void. What action should the nurse take? Give the client a bedpan. 74. A toddler presents to the clinic with a barking cough, strider, refractions with respiration, the child's skin is pink with capillary refill of 2 seconds. Which intervention should the nurse implement? Nebulizer Epinephrine 75. The nurse notes an increase in serosanguineous drainage from the abdominal surgical wound from an obese client. What action should the nurse implement? Observe for wound dehiscence 76. A nurse developing a plan of care for a client diagnosed with Cushing's Syndrome identifies that the client risk factors include: poor wound healing, decrease bone density, & increase capillary fragility. Which outcome statement should the nurse include in the pan of care? Client implements measures to prevent injury 77. After several months on a waiting list an adult male receives a liver transplant last week, the nurse notes that he has developed a macular papular rash on his hands & palms which the client reports it itches & hurts. Which finding of graft versus host is most important to report to the health care provider? Next Cyclosporine dose due tomorrow 78. A woman has been diagnosed with H-Pylori, based on this finding. Which health promotion should the nurse practice? Screen for peptic ulcer 79. A client with glaucoma is receiving Pilocarpine (Isopto) 1% of ophthalmic Sol. 1 drop in each eye. Which intervention is most important for the nurse to implement? Encourage client to blink both eyes not to squeeze 80. A client who is 1 day post MI develops cardiogenic shock receives RX for Dobutamine IV. After the medication has been infusing, the nurse notices that the
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) IV site appears red & tender. Which PRN RX should the nurse administer? Phentolamine (Regitine) 81. A male client reports the onset of numbness & tingling in his fingers & around his mouth. What lab values are most important before contacting the provider? Calcium 82. The nurse takes the morning VS of an elderly male resident at a long term care facility. VS are Temp: 98.7, P: 84, R: 18, B/P: 86/64. Which questions is most important to ask? Are you feeling dizzy? 83. A male client with altered mental status is admitted into the ICU following an MVA. He is SOB, lethargic, & initial ABG's are: pH: 7.33, CO2: 62, HCO3: 35. Which assessment finding is in need of intervention by the nurse? Regular period of 10 second Apnea 84. On admission the ABG's values of a male client with pneumonia are: pH: 7.36, PCO2: 60, PO2: 66, HCO3: 44, O2: 88%, 2 hours later his temperature sparks to 101.5. After 02 by nasal cannula at 2L/min. What action should the nurse implement? Give Antipyretic 85. During the rehabilitation phase of recovery from a burn unit. Which intervention should the nurse include in the plan of care? Assist with lifestyle adjustments 86. An infant who is admitted for surgical repair of Ventricular Septal Defect (VSD). The infant is irritable, diaphoretic, with a JVD. Which RX should the nurse administer first? aldactone spironolactone 87. A woman who lost tooth & injured her RT eye in a bar room fight, is admitted to the ER accompanied by her sister. Both women appear intoxicated & the sister is obviously concerned about the clients condition. Which intervention should the nurse implement? Acknowledge the sisters caring attitude 88. A young adult male who witness a murder of a convenience store operator 6 months ago is brought to the community mental health center by his wife. Started pulling out his eyebrows. When questioned about behavior, he states "It's better than killing someone." Which follow up response is better for the nurse to provide? Tell me about the murder you recently witnessed? 89. When delegating a task to a UAP a newly assigned to a nursing unit. What question is most important for the nurse to ask the UAP? Did you receive any training in performing this task? 90. What is the primary focus of postoperative care for a client trauma? Observation & prevention of infection 91. To obtain an estimate of a clients systolic B/P. What action should the nurse take first? Palpate the brachial pulse 92. A Native American young male adult who suffered a severe brain trauma following a MVA is receiving life mechanical ventilation, his recent EEG, indicates no brain activity, so the provider talks to the family about disconnecting life support. which intervention should the nurse implement? Contact the Shaw Man to come see the client 93. The nurse should teach the parents of a 6 year-old recently DX with asthma that the SX of acute episode of asthma are due to which physiological response? Inflammation of the mucous membrane & bronchospasm
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 94. Which expected outcome statement should the nurse include in a teaching plan assigned to assist the client with management of acute attack of gout? The client would avoid the use of alcohol when managing stress. 95. A male client with RT sided weakness calls for assistance with ambulating to the bathroom. What action should the nurse implement? Stand on the RT side of the client 96. The nurse administered an antibiotic to a client with Respiratory Tract Infection to evaluate the medication effectiveness which lab value should the nurse monitor? Choices are: A. serum K+, B. WBC, C. BUN, D. U/A, E. RBC, F. Serum culture & sensitivity 97. The nurse sees a male client with schizophrenia sitting all alone talking quietly. What action should the nurse take? Ask patient if he's hearing voices 98. The charge nurse is making assignments on an overflow unit in a small rural hospital. Which client has greatest for consistent staff to be assigned to their care? 7 month-old failure to thrive 99. An alert older client with DM type I, is admitted with a serum glucose of 420, as the nurse administers 10 U of Regular Insulin IV, the client immediately begins to vomit: Provide an Emesis Basin 100. In caring for a new born baby who starts gagging & becomes cyanotic. What action should the nurse implement first? Give 3 back blows to clear airway 101. After receiving an IV dose of Zofran prior to chemotherapy the client reports a HA. What action should the nurse take first? Administer a PRN NonOpioid of Analgesics 102. A client presents to the L&D unit "The baby is coming out!" What action should the nurse implement first? Vaginal exam 103. Which self-care measures is most important for the nurse to include in the plan of care of a client DX with DMII? A meal plan 104. Which instruction is most important for the nurse to provide a client that is being discharged following TX of guillain barre syndrome? Plan frequent short rest periods 105. Picture: The nurse prepares to install an adolescents ear drop. Straighten the ear canal 106. A woman just received the Rubella vaccine after a delivery of a normal new born, has two children at home, ages 13 months & 3 yrs old. Which instruction is most important to provide to the client? Do not get pregnant for the next 3 months 107. Prior to insertion of an indwelling catheter. What client information is most important to obtain? Client allergies to antiseptic solutions 108. The nurse is starting insulin infusion for a client with DM who is experiencing HHS, in addition to the client's glucose which lab value is important to monitor? Serum K+ 109. A client with Acute Renal Insufficiency has peaked T-waves on the telemonitor. Which intervention should the nurse administer? Increase IV fluids 110. Nurses working on a MedSurg unit are concerned about a physicians TX of clients during invasive procedures, such as dressing change & insertion of IV
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) lines. Client's that often cry during procedures, the physician is usually unconcerned or annoyed by the client response. To resolve this problem what action should the nurse take? Put in order: 2.Document concerns & report to charge nurse, 1. Talk to the physician in a group in a non confrontation matter, 5. File a complaint with state medical board, 3. Submit a written report to director of nursing, 4. Contact the hospital chief of medical services 111. The UAP assigned to obtain VS reports to the charge nurse that a client has a weak pulse with 44b/m. What action should the charge nurse implement? Notify the heath care provider 112. A male client with CA who is receiving antineoplastic drugs & is admitted with a DX with thrombocytopenia. What findings often manifest with this condition? Erythema & Hematemesis 113. The daughter of an elderly male client tells the nurse that she has gained weight because she is under so much stress deciding whether to put her father in a nursing home care or care for him at home. How should nurse respond? Help the daughter consider the pros & cons or Ask the daughter if the father expressed what he wants 114. A client was admitted to the ICU following an MVA begins to experience Delirium Terming. Which assessment findings should the nurse report to the healthcare provider immediately? Wide QRS complexes & flat T-waves 115. A male infant born at 28 weeks gestation at an outlaying hospital is being transported to a Level 4 neonatal facility HR: 156, R: 92. Which drug is the transport team most likely to administer to the infant? Survanta 116. A client who is admitted with Acute Renal Lithiasis is grimacing & complaining of severe flank pain? Which intervention should the nurse implement first? Administer Opioid Analgesic 117. A nurse is assigned to care for a client with a surgical wound infected with MRSA. The nurse learns that protective environment precautions were started in response to the report of MRA infection. What action should the nurse implement? Replace the protective environment precautions with contact precautions 118. A client with chronic kidney disease for many years has progressed to stage 5functioning . The nurse is preparing the client for hemodialysis. Which comment by the client indicates that client teaching was effective? Dizziness & light headedness must be reported during hemodialysis 119. The UAP reports four clients situations to the nurse. In which sequence should the nurse see the patient's from highest priority to lowest: 1. An adult who has a splenectomy & is vomiting brown coffee grounds, 2. An older adult who has bowel resection & has a fever of 101.4, 3. An older adult who had a laparoscopic cholecystectomy reports pain 6 out of 10, 4. An adult client had several colon polyps removed & refused clear liquids for breakfast. 120. A client with severe full thickness burns is scheduled for an allograft procedure. Which information should the nurse provide for the client? Human allograft source grafts require monitor for infection
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 121. After administering antipyretic. What should the nurse monitor? Encourage fluids 122. After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse? Choices are: A-Periorbital edema, B-Peripheral Cyanosis, C-Weeping Blisters, D-Bilateral Wheezing. 123. At 11:30, the nurse assumes care of an adult client with DM who was admitted with an infected foot ulcer. After reviewing the client's electronic health record, which priority nursing action should the nurse implement? (Click on each chart for additional information. Please be sure to scroll to the bottom RT corner of each tab to view all information contained in the client's medical record.) Choices are: A-Administer insulin per sliding scale, B-Obtain antibiotic peak & trough levels, C-Assess appearance of foot wound, D-Initiate hourly urine output measurements. 124. A 12-year-old child has a BMI of 28, a systolic B/P that is greater than the 95th percentile, & a glycosylated hemoglobin (HbA1c) of 7.8%. Which breakfast selection indicates that his mother understands the management of his diet? Choices are: A-One scrambled egg, 1 pack instant oatmeal, 6 ounce of yogurt, 6 ounces of orange juice. B-Two frosted cinnamon pastry swirls, one banana, 8 ounces of yogurt, 6 ounces apple juice, C-One whole wheat bagel with cream cheese, two strips of bacon, 6 ounces of orange juice. DTwo pieces of peanut butter toast with grape jelly, one small orange, 6 ounces of whole milk. 125. A male client reports to the-on-call clinic nurse that he took tadafil (Cialis) 10mg PO two hours ago & his skin now feels flushed. He reports a HX of stable angina, but denies experiencing any current or recent chest pain. What action should the nurse take? Choices are: A-Advise the client to place one nitroglycerin tablet under his tongue as a precaution. B-Reassure the client that skin flushing is a common side effect of the medication. C-Instruct the client to increase his intake of oral fluids until the skin flushing is relieved. D-Tell the client to have someone bring him to an ED immediately. 126. The nurse is teaching a client with a high LDL cholesterol level about diet modification. Which instruction should the nurse include? Include high fiber foods. 127. VIDEO: During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class, as seen in the video. After the demonstration, the supervising nurse expresses concern that the demonstration procedure increased the client's risk for which problem? Choices are: A-Infection, BImpaired gas exchange, C-Ineffective airway clearance, D-Altered comfort. 128. The charge nurse notes that for the past month a highly-skilled, very responsible RN who has worked on the unit for the past 3 years has been coming in late, leaving early, & completing assignments in an inefficient manner. What action should the charge nurse take? Choices are: A-Report the change in behavior to the nursing supervisor. B-Assign the nurse to less difficult clients. C-Remind the nurse that a full shift must be worked. D-Ask the nurse if there is trouble at home.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 129. A 2-year-old is bleeding from a laceration on the right lower extremity that occurred as the result of a motor vehicle collision. The nurse is selecting supplies to start an IV access. Which assessment finding is most significant in the nurse's selection of catheter size? Choices are: A-Right foot cool to touch. BSwelling at the site of injury. C-Respirations of 24/min. D-Thready brachial pulse. 130. A child receives a RX for dextroamphetamine 10mg PO BID. Dextroamphetamine is available as a 5mg TAB. How many mg/day should the child receives? Enter numeric value: 20 131. The nurse is reviewing the discharge medications with a male client who has a RX for magnesium hydroxide (Milk of Magnesia) 45ml HS for constipation. How many ounces should the nurse instruct the client to take at each dose? Enter numeric value: 1.5 132. Following routine diagnostic tests, a client who is SX-free is DX with Paget's disease. Client teaching should be directed toward what important goal for the patient? Choices are: A-Maintain adequate cardiac output. B-Reduce the risk for injury. C-Promote rest & sleep. D-Promote adequate tissue perfusion. 133. An experienced UAP is hired to work in an antepartal clinic. Which assignment is best for this new employee's first day of work at the clinic? Choices are: A-Accompany the healthcare provider during pelvic examinations, B-Schedule clients for their next antepartal visit to the clinic, C-Discuss good dietary choices with clients using a chart provided by the clinic, D-Take initial VS & urine checks for glucose along with the nurse. 134. A 10-yearold who has terminal brain CA asks the nurse, "What will happen to my body when I die?" How should the nurse respond? Choices are: A-"Your mother & father will be here soon. Talk to them about that." B-"Why do you want to know about what will happen to your body when you die?" C-"The heart will stop beating & you will stop breathing." D-"Are you concerned about where your spirit will go?" 135. PICTURES: An infant is unresponsive & gasping for breath. Prior to starting CPR, which site should the nurse palpate for a pulse? 136. The nurse is taking the social HX of a male client with a DX of gastric ulcer. Which information indicates that this client has a risk factor that exacerbates his ulcer problem? Choices are: A-Able to manage special diet as long as beer is allowed at night. B-Unable to quit truck-driving & has requested shorter routes. C-Difficulty applying stress-reduction techniques & continues to try. D-Refuses to drink milk with meals even if it relieves gastric pain. 137. A client who recently had a CVA is manifesting receptive aphasia. The client is uncooperative & refuses to participate with physical therapy. Which nursing intervention is likely to be most effective when caring for this client? Choice are: A-Provide a letter chart to answer questions. B-Involve speech therapy until client cooperates. C-Use simple gestures & repeat instructions. D-Have client use a notepad to write questions.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 138. The nurse is caring for a 14-year-old whose fractured femur is immobilized using 90-90 skeletal traction. What intervention is most important for the nurse to implement daily? Choices are: A-Give skin & back care with each linen change. B-Encourage adequate bulk & liquids in the diet. C-Provide opportunities for diversion & peer interactions. D-Cleanse pin sites using topical antiseptic & antibiotic. 139. Which client is best to assign to a newly hired UAP on a psychiatric unit? Choices are: A-A client who is experiencing frequent auditory & visual hallucinations. B-A teenager who was admitted during the night following a suicide attempt. C-A schizophrenic client who has been taking antipsychotics for two weeks. D-A bipolar client who is receiving lithium & is dressed in a sexually provocative manner. 140. During a TURP, the prostate capsule was perforated. Postoperatively, the client is receiving continuous bladder irrigation & complains of back pain. Which assessment finding warrants immediate intervention by the nurse? Choices are: A-Nausea & Vomiting. B-Spasms in leg muscles. C-Pain score of 7 out of 10. D-Elevated temperature.
141. 142. 143. 144. 145. 146.
These are other notes: Kawasaki: Assess Pt Pulse. Child health teaching Lyme Disease: Put Deet spray Pt with fever: Increase or allow more fluids. Gastro By-Pass: Monthly Vitamin B12 injections Type 2 diabetes newly diagnosed teaching = Self glucose monitoring
147.
Diabetic foot care = wear shoes in the house
148.
Hyperglycemia causes vomiting = turn patient on their side
149. At highest risk for UTI = the lady who sits down and does not go to the bathroom at her job. ( I may be a little off with this one) 150. Diaper weight for newborn= Subtract the new diaper from the used diaper 151. Signs and symptoms of diabetes insipidus from a head injury 152. There was a question on how to do a newborn assessment that was to be put in the correct order (drag and drop). 1) respirations, 2) heart rate, 3) temperature 153.
Magnesium sulfate= Calcium gluconate (anti-dote)
154.
A patient with COPD (its a video) and he's doing it incorrectly.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 155. A patient with Borderline personality= dichotomous thinking (black and white, all good or all bad) 156. A patient is having sex relations with their spouse in the hospital = Close the door and leave the room 157. Perineal laceration: Stool softener 158. Mylicon: Antiflatus 159. Dementia coordination: Finger Foods 160. Pneumatic Compression Device: Post op 5 days bed rest. 161. Skin assessing blanching: Apply pressure to the site.
HESI V1 2018 EXIT EXAM QUESTIONS 2. A client who is admitted to the care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first? A) Patch one eye. B) Evaluate swallow. C) Reorient often. D) Range of motion. 3. The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply) A) Wash the stump with soap and water. B) Avoid range of motion exercise. C) Apply alcohol to the stump after bathing. D) Inspect skin for redness. E) Use a residual limb shrinker. 4. After 2 days treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing and the child’s urine output is 50ml/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which should the nurse implemented? A) Increase the IV fluid flow rate. B) Review 24 hour intake and output. C) Obtain arterial blood gases. D) Perform a finger stick glucose test. 6. A male client with an antisocial personality disorder is admitted to an in patient mental health unit for multiple substance dependency. When providing a history, the client justifies to the nurse his use of illicit drugs. Based on this pattern of behavior, this client’s history is most likely to include which finding?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) A) Multiple convictions for misdemeanors and Class B felonies B) Delusions of grandiosity and persecution. C) Suicidal ideations and multiple attempts. D) Photos and panic attacks when confronted by authority figures. 7. An older client is admitted for repair of a broken hip. To reduce the risk for infection postoperative period., which nursing care intervention should the nurse include the client’s plan of care? (Select all that apply) A) Administer low molecular weight heparin as prescribed. B) Teach client to use incentive spirometer every 2 hours while awake. C) Remove urinary catheter as soon as possible and encourage voiding. D) Maintain sequential compression devices while in bed. E) Assess pain level and medicate PRN as prescribed. 9. A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? A) Serum Calcium. B) Erythrocyte sedimentation rate. C) Osmolality. D) Hemoglobin. 10. A client with bacterial meningitis is receiving phenytoin. Which assessment finding indication to the nurse that the client is experiencing a therapeutic response to the phenytoin? A) Increased time of ambulation between periods of rest. B) Decrease in intracranial pressure and cerebral edema. C) Absence of seizure activity for the duration of treatment. D) Normal electroencephalogram after drug administration. 11. A client peptic ulcer disease receives a prescription for intermittent suction via a SalemSump nasogastric tube (NGT). After inserting the NGT and obtaining coffee-ground gastric contents, the nurse clamps the NGT because the client must leave the unit for diagnostic studies. Upon return to the unit, the client complains of nausea. What action should the nurse implement first? A) Administering a prescribed antiemetic agent. B) Provide oral suction using a Yankauer tip. C) Connect the NGT to low intermittent suction. D) Irrigate the NGT with sterile normal saline. 12. The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 ml to be influenced over 4 hours. The IV administration set delivers 10 gtt/ml. How many gtt/minute should the nurse regulate the infusion? ( round the nearest whole number.) 13. A family member reports that the client who is bedridden has not been turned or repositioned all night and is sleeping on a special air mattress with no sheets. What information should the nurse provide to the family member? A) Clarify that an aerated support surface does not use sheets that often cause skin breakdown.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) B) Described the night staff’s plan of care to ensure the client’s sleep is not disturbed. C) Explained that turning is only necessary to reposition the client during waking hours. D) Suggest that a family member turn the client during the night when someone is there. 15. A client with bleeding esophageal varies receives vasopressin IV. What should the nurse monitor for during the IV infusion of this medication? A) Vasodilation of the extremities. B) Chest pain and dysrhythmia. C) Hypotension and tachycardia. D) Decreasing GI cramping and nausea. 16. The healthcare provider prescribes potassium chloride 25 mEq in 500ml D5W to infuse over 6 hours. The available 20ml vial of potassium chloride is labeled, “How many ml of potassium chloride should the nurse add to the IV fluid? (Round to the nearest tenth.) • 12.5 •
Rationale: Using the formula D / H X Q: 25 mEq / 10 mEq x 5ml ꞊12.5ml
17. A male client reports to the on-call clinic nurse that he took tadalif 10 mg PO two hours age and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any current or recent chest pain. What action should the nurse take? A) Tell the client to have someone bring him to an emergency department immediately. B) Advise the client to place one nitroglycerin tablet under his tongue as a precaution. C) Reassure the client that skin flushing is a common side effect of the medication. D) Instruct the client to increase his intake of oral until the skin flushing is relieved. 18.The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease (CKD). Which assessment finding should the nurse report to the healthcare provider? A) The client complains of abdominal fullness and cramping during installation. B) The client complains of a slight shortness of breath during installation. C) The amount of the returning dialysis fluid is greater than the amount instilled. D) The appearance of the returning dialysate fluid is cloudy. 19. The healthcare provider prescribed furosemide for a 4-year old child who has a ventricular septal defect. Which outcome indicates to the nurse that this pharmacological intervention was effective? A) Urine specific gravity change from 1.021 to 1.031 B) Daily weight decrease of 2 pounds (0.9 kg) C) Urinary output decrease of 5 ml/hour. D) Blood urea nitrogen (BUN) increase from 8 to 12 mg/dl (2.9 to 4.3) 20. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication? A) Ask the client about soft food preferences. B) Determine which side of the body is weak. C) Obtain and record the client’s vital signs.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) D) Auscultate the client’s breath sounds. 21. The nurse is demonstrating correct transfer procedures to the unlicensed assistance personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely move a physically disabled client from the wheelchair to a bed. What action the nurse recommend? A) Apply a gait belt around the client’s waist once a standing position has been assumed. B) Pull the client into position by reaching from the opposite side of the bed. C) Hold the client at arm’s length while transferring to better distribute the body weight. D) Place the client’s locked wheelchair on the client’s strong side next the bed.
22. A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond? A) Provide information about survival rates women who have this genetic mutation. B) Gather additional information about the client’s family history for all types of cancer. C) Offer assurance that there are a variety of effective treatments for breast cancer. D) Explain that counseling will be provided to give her information about her cancer risk. 23. The nurse is supervising an unlicensed assistive personnel (UAP) who will be providing personal care for a client with watery diarrhea caused by Clostridium difficile. Which action by the nurse takes priority? A) Remind the UAP to keep the client’s water pitcher filled. B) Review use of personal protective equipment with the UAP. C) Provide barrier cream for application to the perineal area. D) Instruct the UAP to record the number of bowel movements. 24. The nurse enters the room of a client who is awaiting surgery for appendicitis. The unlicensed assistive personnel (UAP) has helped the client to a position of comfort with the right leg flexed and has applied a heating pad to the client’s abdomen to relieve the client’s pain. Which action should the nurse implement first? A) Determine if the consent form has been signed by the client. B) Remove the heating pad from the client’s abdominal area. C) Confirm that the UAP has assisted the client to a position of comfort. D) Evaluate the effectiveness of the heating pad in relieving pain. 25. The nurse completed a dressing change for a client with partial thickness burns to both legs. After completing the dressing change, What intervention should the nurse implement? A) Administer a PRN dose of pain medication. B) Raise this head of bed to a 90 angle. C) Perform passive range of motion. D) Position ankles in a dorsiflexed position. 26. A client is admitted to a medical unit with a diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke’s syndrome? A) Atenolol. B) Famotidine. C) Thiamine. D) Lorazepam.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 27. Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. What action should the nurse take? A) Apply bilateral eye shields to reduce photosensitivity. B) Begin postoperative prophylactic antibiotics. C) Administer an antiemetic to prevent vomiting. D) Report the complain of eye pain to the surgeon. 28. A male client with cirrhosis has jaundice and pruritis. He tells the nurse that he was been soaking in hot baths at night with no relief of his discomfort. What action should the nurse take? A) Explain that the symptoms are caused by liver damage and cannot be relieved. B) Encourage the client to use cooler water and apply calamine lotion after soaking. C) Obtain a PRN prescription for an analgesic that the client can use for symptom relief. D) Suggest that the client take brief showers and apply oil-based lotion after showering. 30. A 17-year-old adolescent is brought to the Emergency Department by both parents because the adolescent has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first? A) Assess the client’s temperature. B) Place a mask on the client’s face. C) Determine the client’s blood pressure. D) Obtain a chest x-ray per protocol. 31. The nurse is preparing to administer an IV dose of ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse? A) White blood cell count of 12,000 mm^3 (12 x 10^9/L SI) B) Serum sodium of 145 men/L (145 mm/L SI) C) Urine culture positive for MRSA. D) Serum creatinine of 4.5mg/dl (398 mom/L SI) 32. A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider? A) Reports white, curly vaginal discharge. B) Last menstrual period 7 weeks ago. C) History of irritable bowel syndrome (IBS) D) Pain scale rating of a “9” on a 0-10 scale. 33. A client is admitted to the intensive care unit with diabetes insidious due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? A) Ketonuria. B) Peripheral edema. C) Hypokalemia. D) Elevated blood pressure. 34. A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine sulfate 4 mg IV. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which intervention is most important for the nurse to include in this client’s plan of care?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) A) Assess for back muscle aches. B) Obtain body weight daily. C) Monitor urinary output hourly. D) Record drainage from drain. 36. When administering ceftriaxone sodium intravenously to a client before surgery, which assessment finding requires the most immediate intervention b the nurse. A) Headache. B) Pruritis. C) Stridor. D) Nausea. 37. The nurse is complaining an admission assessment for a male client with paranoid schizophrenia. The client tells the nurse that the staff dislikes him. What action should the nurse take? A) Assess the client’s speech pattern for a flight of class. B) Observe the client for obsessive activities such as repeated hand washing. C) Determine if the client has formulated any plans regarding the staff. D) Ask the client if he has a plan to harm himself. 39. The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using a Medela Haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple’s elongated tip in the back of the oral cavity. What instruction should the nurse provide the mother about feedings? A) Alternate milk with water during the feedings. B) Squeeze the nipple base to introduce milk into the mouth. C) Position the baby in the left lateral position after feeding. D) Hold the newborn in an upright position. 40. When caring for a client with a traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past 8 hours the client’s GCS score has been 14. What goes this GCS finding indicate about this client? A) Rehabilitative prognosis is an expected full recovery. B) Insertion of an ICP monitoring device is necessary. C) Neurologically stable without indications of an increased ICP. D) Risk for irreversible cerebral damage related to increased ICP. 41. While caring for a client’s postoperative dressing the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without daring. Which is the most important action for the nurse to take? A) Determines if the drainage has an unpleasant B) Cleanse the wound with a sterile saline solution. C) Request a culture and sensitivity of the wound. D) Monitor the client’s white blood cell count (WBC).
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 42. Following morning care, a client with a C-% spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which interventions should the nurse implement first? A) Assess the client’s blood pressure every 15 minutes. B) Relieve any kinks or obstruction in the client’s Foley tubing. C) Teach the client to response symptoms of dyreflexia. D) Administer a prescribed PRN dose of hydrazine (Apresoline.) 43. The nurse is planning care for a young adult client with acromegaly. It is most important for the nurse to monitor which of the client’s serum laboratory test results? A) White blood cell count. B) Glucose. C) Hemoglobin. D) Partial thromboplastin time. 44. A client with history of adrenal insufficiency is admitted to the intensive care unit with an acute adrenal crisis. The client is complaining of nausea and joint pain.Vital signs are: temperature 102 F (38.9 C) heart rate 138 beats/minute, blood pressure 80/60 mmHg. Which intervention should the nurse implement first? A) Administer PRN oral antipyretic. B) Infuse an intravenous fluid bolus. C) Obtain an analgesic prescription. D) Cover client with cooling blanket. 45. The nurse supplies a blood pressure cuff around a client’s left thigh. To measure client’s pressure, where should the diaphragm of the stethoscope be placed? (Mark location on image) 46. The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendations for hypertension? A) Grilled steak, baked potato with sour cream, green beans, coffee. B) Beef stir fry, fried rice, egg drop soup, Diet Coke, and pumpkin pie. C) Tomato soup, grilled cheese sandwich, pickles, skim milk, and lemon menage pie. D) Baked pork chop, applesauce, corn on the cob, 1% milk, and key lime pie. 47. A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? A) Referral for social services for the child and family. B) Instruction about how much fluid the child should drink daily. C) Signs of addiction to opioid pain medications. D) Information about non-pharmaceutical pain relief measures. 50. A client who had a percutaneous coronary intervention (PCI) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction of 30%. Today the client has links which are clear, +1 pedal edema, and a 5 pound weight gain. Which intervention should the nurse implement? A) Insert saline lock for IV diuretic therapy. B) Arrange transport for admission to the hospital. C) Assess compliance with routine prescriptions.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) D) Instruct the client to monitor daily caloric intake. 53. Following a gunshot wound, an adult client has a hemoglobin level 4 grams/dl (40 mmil/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of Type A Rh negative, reporting that there is no Type AB negative blood currently available. Which intervention should the nurse implement? A) Administer normal saline solution until Type AB negative is available. B) Obtain additional consent for administration of Type A negative blood. C) Transfuse Types A negative blood until Type AB negative is available. D) Recheck the client’s hemoglobin, blood type, and Rh factor. 55. An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take? A) Prepare the client for an echocardiogram. B) Limit the client’s fluids. C) Document in the client’s record. D) Notify the healthcare provider. 57. Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain? A) Balance and posture. B) Pressure sore risk. C) Risk for disuse syndrome. D) Upper body muscle strength. 59. A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face and on the front of the child’s clothes. After ensuring the airway is patent, what action should the nurse implement first? A) Obtain equipment for gastric lavage. B) Determine type of chemical exposure. C) Assess child for altered sensorium. D) Call poison control emergency number. 60. The nurse enters room of a client with Parkinson’s disease who is taking carbidopa levodopa. The client is arising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take? A) Demonstrate how to help the client move more efficiently. B) Affirm that the client should arise slowly from the chair. C) Tell the UAP to assist the client in moving more quickly. D) Offer a PRN analgesic to reduce painful movement. 62. A middle aged female client tells the clinic nurse that she has lost an inch of height in the last year. What is the priority nursing intervention? A) Assist the client to schedule a bone density exam. B) Observe for the presence of a dowager’s C) Advice the client to begin stretching exercises.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) D) Encourage the client to eat calcium rich foods. 63. An adult female tells the nurse that her grandmother was diagnosed with colorectal cancer at age 75 and the client is implementing measures to reduce her own risk. Which of the client’s plans indicates the need for additional information? A) Annual sigmoidoscopy screening. B) Increased intake of fresh fruits, vegetables, and whole grains. C) Reduced dietary intake of animal fat and protein. D) Yearly fecal occult blood testing. 64. In early septic shock states, what is the primary cause of hypotension? A) Peripheral vasodilation. B) Cardiac failure. C) A vagal response. D) Peripheral vasoconstriction. 65. Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess first? A) A 3-week multigravida with a prescription for serial blood pressures. B) A 39-week primigravida with biophysical profile score of 5 out of 8. C) A 38- week primigravida who reports contractions occurring every 10 minutes. D) A 41-week multigravida who is scheduled induction of labor today. 65. A male client with cirrhosis has jaundice and pruritis. He tells the nurse that he has been soak in hot baths at night with no relief of his discomfort. What action should the nurse take? A) Suggest that the client take brief showers and apply oil-based lotion after showering. B) Explain that the symptoms are caused by liver damaged and cannot be relieved. C) Encourage the client to use cooler water and apply calamine lotion after soaking. D) Obtain a PRN prescription for an analgesic that the client can use for symptom relief. 67. An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)? A) 36% B) 9% C) 45% D) 15% 68. 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? A) Remind the client that a rescue inhaler might save his life. B) Gently touch the client then continue with the teaching. C) Ask the client what he is thinking about at this time. D) Leave the client alone so that he can grieve his illness.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 70. A male client is admitted to the hospital due to multiple fractures following a motor vehicle collision that occurred when he ran his car into his ex-spouse’s home. When the client becomes angry and starts throwing objects at the staff, which PRN prescription should the nurse implement? A) Apply soft wrist restraints if needed for client safety. B) Consult with the chaplain emotional support. C) Hydromorphone (Dilaudid) 2mg IV. D) Haloperidol (Haldol) 1mg IM. 71. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What in the reason for this intervention ? A) To promote retraction of the intercostal accessory muscles. B) To reduce abdominal pressure on the diaphragm. C) To decrease pressure on the medullary center which stimulates breathing. D) To promote bronchodilation and effective airway clearance. 72. As adult client’s apical pulss is 110 beats per minute. What intervention should the nurse implement first? A) Assess the client’s radial pulse and apical pulse at the same time. B) Assess the client to determine the reason why the pulse is elevated. C) Notify the charge nurse that the client’s pulse is elevated. D) Attempt to calm the client and take the pulse again in one hour. 74. The nurse is planning discharge teaching for a client who had an evacuation of gestational trophoblastic disease (GTD) two days age. Which information is most important for the nurse to include in this client’s teaching plan? A) Location and times for a local support group. B) Rho(D) immune globulin to prevent isoiminuization. C) Schedule follow up visit with the healthcare provider. D) Oral contraceptive use for at least one year. 77. An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/ml. How many ml should the nurse adminster? (If rounding required, round to the nearest tenth.) • 0.4 •
Rationale: Calsulate using the formula, desired dose (220,000 units) over dose on hand (600,000 units) x the volume of the available dose (1 ml). 220,000 / 600,000 x 1 ml = 0.36 = 0.4 ml
83. A client with multiple sclerosis is receiving baclofen 15mg PO three times daily. The drug is available in 10 mg tablets. How many tablets should the nurse administer in a 24 hour period? (Round to nearest tenth.) A client with multiple sclerosis and muscle spasms receives a prescription for baclofen (Kemstro) 30 mg PO daily. The medication is supplied from the pharmacy in 20 mg scored tablets. How many tablets should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) tenth.) Use ratio and proportion, 30 mg : X tablets = 20 mg : 1 tablet 20X = 30 X = 1.5 84. An adult client with a broken femur is transferred to the medical surgical unit to await surgical internal fixation after the application of an external traction device to stabilizer the leg. An hour after an opioid analgesic was administered, the client reports muscle spasm and pain at the fracture site. While waiting for the client to be transported to surgery, which action the nurse implement? A) Reduce the weight on the traction device. B) Administer PRN dose of a muscle relaxant. C) Observe for signs of deep vein thrombosis. D) Check client’s most recent electrolyte values. 85. A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusions rate for the heparin solution at 18 units?kg/hour. The available solution is Heparin Sodium 25,000 Units in 5% Dextrose Injection 250ml. The nurse should program the infusion pump to deliver how many ml/hour? 86. While assisting a client who recently had a hip replacement onto the bed pan, the nurse notices that there is a small amount of bloody drainage on the on the surgical dressing, the client’s skin is warm to touch, and there is a strong odor from the urine. Which action should the nurse take? A) Remove dressing and assess surgical. B) Measure the client’s oral temperature. C) Insert an indwelling urinary catheter. D) Obtain a urine sample from the bed pan. 88. What information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms? A) Avoid using heat or ice to injured muscles while taking this medication. B) Use cold and allergy medications only as directed by a healthcare provider. C) Take the medication on an empty stomach. D) Discontinue all non steroidal anti-intiflammatory medications. 89. An older adult male is admitted with complication related to Chronic Obstructive Pulmonary Disease (COPD). He reports progressive dyspnea that worens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? A) Limit the intake of high calorie foods. B) Maintain a low protein diets. C) Eat meals at the same time daily. D) Restricts daily fluid intake. 90. A 6- year-old child who had surgery yesterday absolutely refuses to use the incentive spirometer. Which intervention should the nurse implement?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) A) Ask the mother to assist when it is time to use the spirometer. B) Allow child to choose when to perform incentive spirometry. C) Contract with the child to use spirometer only after meals. D) Blow out lights, blow bubbles, and encourage child’s laughing. 92. A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement? A) Recommend he avoid fast food restaurants until he is familiar with his prescribed diet. B) Advise him to take his own food with him when going to fast food restaurants with his friends. C) Encourage him to find activities to do with his friends that do not involve eating. D) Assist him in identifying popular fast foods that are within his meal plan for diabetes. 95. The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who his frequent urinary incontinence while the client is positioned on a bedpan. What action the nurse take? A) Recommend a complete bath to cleanse the perineal area more fully. B) Instruct the PN that this technique promotes infection in elderly females. C) Evaluate the effectiveness of this measure to stimulate client voiding. D) Suggest contacting the healthcare provider for a prescription for Cather insertion. 105. A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a “Do Not Resuscitate” prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. What action should the nurse take? A) Encourage the UAP to provide comfort care measures only. B) Assume total care of the client to monitor neuralgic function. C) Advise the UAP to resume positioning the client on schedule. D) Assign a practical nurse to assist the UAP in turning the client. 111. When attempting to establish risk reduction strategies in a community, the nurse note that regional studies indicates a high number of persons with growth stunting and irreversible mental deficiencies caused by hypothyroidism (cretinism). The nurse should seek funding to implement which screening measure? A) TSH levels in women over 45. B) T3 levels in school-aged children. C) T4 levels in newborn. D) Iodine levels in all persons over 60. 112. An infant is unresponsive and gasping for breath. Prior to start CPR, which site should the nurse palpate for a pulse? (Image) 114. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the to explore further prior to the start of the procedure? A) Drank a glass of water in the past 2 hours. B) Reports left chest wall pain prior to admission. C) Verbalize a fear of being in a confined space. D) Experience facial swelling after eating crab.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 116. An older female client living in a low-income apartment complex nurse that she is concerned about her 81-year-old neighbor, a widow whose son recently assumed her financial affairs. Lately, her neighbor has become reclusive, but is occasionally seen walking outside wearing only a robe and slippers. What response should the nurse offer? A) Provide the number for Adult Protective Services so the client can report any suspicion of elder abuse. B) Encourage the client to avoid becoming involved in the neighbor’s problems, for one’s own protection. C) Tell the client to talk to a healthcare provider before reporting suspicion of neglect to the authorities. D) Explain that it is not unusual for older adults to suffer from dementia, which often causes such behaviors. 117. Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is transferred to the near intensive care unit with a temperature of 102.8 F (39.3 C) axillary, pulse of 180 beats/minute, and a blood pressure of 90/60. What its the priority intervention to include in the client’s plan care? A) Maintain intravenous access. B) Keep the suture line clean and dry. C) Measure hourly urine output. D) Check near vital signs q4 hours. 121. A nurse who is working the emergency department triage area is presented with four client the same time. The client presenting with which symptoms requires the most immediate intervention by the nurse? A) Unable to bear weight on the left foot, with swelling and bruising. B) Chest discomfort one hour after consuming a large, spicy meal. C) One-inch bleeding laceration on the chin of a crying 5-year olfd D) Low-grade fever, headache, and malaise for the past 72. 122. The nurse assesses a client who had bilateral total knee replacement (TKR) four hours ago. The nurse that the dressing on the client’s right knee is saturated with serosanguineous drainage. What actions should the nurse implement? A) Confirm that the continuous passive motion device is intact. B) Withhold next scheduled dose of low molecular weight heparin. C) Monitor the client’s current white blood cell count (WBC) D)Determine if the wound drainage device is suctioning correctly. 123. A small round area appears under the client’s skin as the administer an intradermal medications. What action should the nurse take? A) Elevate the area and apply light pressure over the site. B) Notify the healthcare provider of the allergic response. C) Document the site where the medication was given. D) Apply a cold pack to the area for twenty minutes. 125. A client taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) A) Observe the appearance of the stool. B) Review the client’s laboratory values. C) Auscultate the client’s bowel sounds. D) Assess the elasticity of the client’s skin. 126. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rates the pain 5 on a pain scale of 0 to 10. The client’s blood pressure is currently 142/89. Which intervention should the nurse implement? (Select all that apply). A) Notify the healthcare provider immediately. B) Administer a daily dose of lisinopril as scheduled. C) Withhold the next scheduled daily dose of warfarin. D) Provide a PRN dose of acetaminophen for headache. E) Assess the client for postural hypotension. 127. During a Women’s Health Fair, which assignment is best for the practical nurse (PN) who is working with a registered nurse (RN)? A) Encourage a woman at risk for cancer to obtain a colonoscopy. B) Present a class on bread self-examination. C) Explain the follow up needed for a client with prehypertension. D) Prepare a woman for a bone density screening. 129. During the administration of albuterol per nebulizer, the client complains of shakiness. The client’s vital signs are heart rate 120 beats/minutes, respirations 20 breaths/minute, blood pressure 140/88. What action should the nurse take? A) Administer an anxiolytic. B) Obtain 12 lead electrocardiogram. C) Educate client about the side effects of albuterol. D) Stop the albuterol administration and restart in 30 minutes. 130. The nurse is measuring the output of an infant admitted for vomiting and diarrhea. During a 12- hour shift, the infant drinks 4 ounces of Pedialyte, vomits 25 ml, and voids twice. The dry diaper weight is 50 grams, and one wet diaper weight 75 grams, and the other weights 105 grams. Which computer documentation should the nurse enter in the infant’s record? A) Document in the flow sheet that the infant voided times 2 and vomited 25 ml. B) Calculate differences in wet and dry diapers and document 80 ml urine output. C) Compare the difference between the infant’s body weight and admission weight. D) Subtract vomits from 120 ml Pedialyte than document 95 ml oral intake. 131. On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain? A) Which family member has the client’s suicide note. B) What drugs the client used for the suicide attempt. C) When the client last took drugs for bipolar disorder. D) Whether the client ever attempted suicide in the past.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) •
132. During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client’s point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location)
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An older male adult resident of long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.) • Notify the healthcare provider of the client’s change in mental status. • Include q2 hour’s reorientation in the client’s plan of care.
133. The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply.) A. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). B. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty C. Perform daily surgical dressing change for a client who had an abdominal hysterectomy D. Initiate patient controlled analgesia (PCA) pumps for two clients immediately postoperative E. Start the second blood transfusion for a client twelve hours following a below knee amputation ...
2019 HESI EXIT V1 1. Which information is a priority for the RN to reinforce to an older client after intravenous pylegraphy? A) Eat a light diet for the rest of the day
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) B) Rest for the next 24 hours since the preparation and the test is tiring. C) During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days D) Measure the urine output for the next day and immediately notify the health care provider if it should decrease. The correct answer is D: Measure the urine output for the next day and immediately notify the health care provider if it should decrease. 2. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is A) difference in the intake and output B) changes in the mucous membranes C) skin turgor D) weekly weight The correct answer is D: weekly weight 3. A client has been diagnosed with Zollinger-Ellison syndrome.Which information is most important for the nurse to reinforce with the client? A) It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum) B) It is critical to report promptly to your health care provider any findings of peptic ulcers c)Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors D)With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine The correct answer is B: It is critical to report promptly to your health care provider any findings of peptic ulcers . 4. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client’s blood pressure is increasing. Which action should the nurse take first? A) Check the protein level in urine B) Have the client turn to the left side C) Take the temperature D) Monitor the urine output The correct answer is B: Have the client turn to the left side 5. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? A) Diminished bowel sounds B) Loss of appetite C) A cold, pale lower leg D) Tachypnea The correct answer is C: A cold, pale lower leg
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 6. The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? A) Nausea and vomiting B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius) C) Diffuse macular rash D) Muscle tenderness The correct answer is B: Fever of 103 degrees F (39.5 degrees C) 7. A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? A) Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception. B) This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate. C) After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days. D) The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort. The correct answer is A: Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception. 8. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? A) Some needles go as deep as 3 inches, depending on where they're placed in the body and what the treatment is for. The needles usually are left in for 15 to 30 minutes. B) In traditional Chinese medicine, imbalances in the basic energetic flow of life — known as qi or chi — are thought to cause illness. * C) The flow of life is believed to flow through major pathways or nerve clusters in your body. D) By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations it is believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over. The correct answer is C: The flow of life is believed to flow through major pathways or nerve clusters in your body. 9. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? A) It also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes. B) In the second phase of the disease, findings include peeling of the skin on the hands
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) and feet with joint and abdominal pain C) Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent D) Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to2 weeks The correct answer is C: Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent 10. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? A) Side-lying on the left with the head elevated 10 degrees B) Side-lying on the left with the head elevated 35 degrees C) Side-lying on the right wil the head elevated 10 degrees D) Side-lying on the right with the head elevated 35 degrees The correct answer is A: Side-lying on the left with the head elevated 10 degrees 11. A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? A) Light, pink urine B) occasional suprapubic cramping C) minimal drainage into the urinary collection bag D) complaints of the feeling of pulling on the urinary catheter The correct answer is C: minimal drainage into the urinary collection bag 12. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client’s pulse and respirations, what should be the function of the second nurse? A) Relieve the nurse performing CPR B) Go get the code cart C) Participate with the compressions or breathing D) Validate the client's advanced directive The correct answer is C: Participate with the compressions or breathing 13. The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? A) Decreased urinary output B) Jugular vein distention C) Pleural effusion D) Bibasilar crackles The correct answer is B: Jugular vein distention 14. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) A) Can predispose to dysrhythmias B) May lead to oliguria C) May cause irritability and anxiety D) Sometimes alters consciousness The correct answer is A: Can predispose to dysrhythmias 15. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? A) Flaccid paralysis B) Pupils fixed and dilated C) Diminished spinal reflexes D) Reduced sensory responses The correct answer is B: Pupils fixed and dilated 16. A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis? A) ‖I knew this would happen. I've been eating too much red meat lately." B) ‖I really enjoyed my fishing trip yesterday. I caught 2 fish." C) ‖I have really been working hard practicing with the debate team at school." D)‖I went to the health care provider last week for a cold and I have gotten worse." The correct answer is D: "I went to the doctor last week for a cold and I have gotten worse." 17. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? A) Hemoglobin level of 12 g/dI B) Pale mucosa of the eyelids and lips C) Hypoactivity D) A heart rate between 140 to 160 The correct answer is B: Pale mucosa of the eyelids and lips 18. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is A) Heart rate B) Pedal pulses C) Lung sounds D) Pupil responses The correct answer is D: Pupil responses 19. Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? A) A young adult with a history of Down's syndrome B) A teenager who reads at a 4th grade level C) An elderly client with numerous arthritic nodules on the hands D) A preschooler with intermittent episodes of alertness
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) The correct answer is D: A preschooler with intermittent episodes of alertness 20. The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be A) Irritable and "colicky" with no attempts to pull to standing B) Alert, laughing and playing with a rattle, sitting with support C)Skin color dusky with poor skin turgor over abdomen D) Pale, thin arms and legs, uninterested in surroundings The correct answer is D: Pale, thin arms and legs, uninterested in surroundings 21. As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss The correct answer is D: Hair loss 22. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to A) Call the health care provider immediately B) Administer acetaminophen as ordered as this is normal at this time C) Send blood, urine and sputum for culture D) Increase the client's fluid intake The correct answer is B: Administer acetaminophen as ordered as this is normal at this time 23. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be A) Cover the areas with dry sterile dressings B) Assess for dyspnea or stridor C) Initiate intravenous therapy D) Administer pain medication The correct answer is B: Assess for dyspnea or stridor 24. Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? A) I started my period and now my urine has turned bright red. B) I am an diabetic and today I have been going to the bathroom every hour. C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom. D) I went to the bathroom and my urine looked very red and it didn’t hurt when I went. The correct answer is D: I went to the bathroom and my urine looked very red and it
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) didn’t hurt when I went. 25. A middle aged woman talks to the nurse in the health care provider’s office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? A) I am one out of every 4 women that get fibroids, and of women my age – between the 30s or 40s, fibroids occurs more frequently. B) My fibroids are noncancerous tumors that grow slowly. C) My associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination or urine retention and constipation. D) Fibroids that cause no problems still need to be taken out. The correct answer is D: Fibroids that cause no problems still need to be taken out. 26. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next? A) Stay with client and observe for airway obstruction B) Collect pillows and pad the side rails of the bed C) Place an oral airway in the mouth and suction D) Announce a cardiac arrest, and assist with intubation The correct answer is A: Stay with client and observe for airway obstruction 27. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor? A) FHT 168 beats/min B) Temperature 100 degrees Fahrenheit. C) Cervical dilation of 4 D) BP 138/88 The correct answer is A: FHT 168 beats/min 28. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse’s initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? A) "I have a sharp pain in my chest when I take a breath." B) "I have been coughing up foul-tasting, brown, thick sputum." C) "I have been sweating all day." D) "I feel hot off and on." The correct answer is B: "I have been coughing up foul tasting, brown, thick sputum." 29. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal A) S3 ventricular gallop
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) B) Apical click C) Systolic murmur D) Split S2 The correct answer is A: S3 ventricular gallop 30. Which of these observations made by the nurse during an excretory urogram indicate a complicaton? A) The client complains of a salty taste in the mouth when the dye is injected B) The client’s entire body turns a bright red color C) The client states ―I have a feeling of getting warm.‖ D) The client gags and complains ― I am getting sick.‖ The correct answer is B: The client’s entire body turns a bright red color 31. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? A) "The tube will drain fluid from your chest." B) "The tube will remove excess air from your chest." C) "The tube controls the amount of air that enters your chest." D) "The tube will seal the hole in your lung." The correct answer is B: "The tube will remove excess air from your chest." 32. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? A) Blood urea nitrogen 50 mg/dl B) Hemoglobin of 10.3 mg/dl C) Venous blood pH 7.30 D) Serum potassium 6 mEq/L The correct answer is D: Serum potassium 6 mEq/L 33. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse’s immediate attention? A) Pallor B) Increased temperature C) Dyspnea D) Involuntary muscle spasms The correct answer is C: Dyspnea 34. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? A) Breath sounds can be heard bilaterally B) Mist is visible in the T-Piece C) Pulse oximetry of 88 D) Client is unable to speak The correct answer is C: Pulse oximetry of 88 35. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) that the client may need suctioning? A) drowsiness B) complaint of nausea C) pulse rate of 92 D) restlessness The correct answer is D: restlessness 36. The most effective nursing intervention to prevent atelectasis from developing in a post operative client is to A) Maintain adequate hydration B) Assist client to turn, deep breathe, and cough C) Ambulate client within 12 hours D) Splint incision The correct answer is B: Assist client to turn, deep breathe, and cough 37. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote A) Relaxation and sleep B) Deep breathing and coughing C) Incisional healing D) Range of motion exercises The correct answer is B: Deep breathing and coughing 38. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? A) Ask client to cough sputum into container B) Have the client take several deep breaths C) Provide a appropriate specimen container D) Assist with oral hygiene The correct answer is D: Assist with oral hygiene 39. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority? A) Blanch nail beds for color and refill B) Assess for post operative arrhythmias C) Auscultate for pulmonary congestion D) Monitor equality of peripheral pulses The correct answer is B: Assess for post operative arrhythmias 40. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first? A) Obtain a 12-lead EKG B) Place client in high Fowler's position C) Lower the oxygen rate D) Take baseline vital signs
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) The correct answer is C: Lower the oxygen rate 41. A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first? * A) Notify the health care provider B) Readjust the traction C) Administer the ordered prn medication D) Reassess the foot in fifteen minutes The correct answer is A: Notify the health care provider 42. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to A) Wrap the leg with elastic bandages B) Apply pressure at the bleeding site C) Reinforce the dressing and elevate the leg D) Remove the dressings and re-dress the incision The correct answer is C: Reinforce the dressing and elevate the leg 43. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care? A) Esophagitis B) Leukopenia C) Fatigue D) Skin irritation Review Information: The correct answer is B: Leukopenia 44. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Prepare for blood transfusion D) Continue to monitor the rate of drainage The correct answer is D: Continue to monitor the rate of drainage 45. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? A) Increased blood pressure B) Increased heart rate C) Loss of pulse in the extremity D) Decreased urine output The correct answer is C: Loss of pulse in the extremity
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 46. A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? A) Have him drink several glasses of water B) Crede’ the bladder from the bottom to the top C) Assist him to stand by the side of the bed to void D) Wait 2 hours and have him try to void again The correct answer is C: Assist him to stand by the side of the bed to void 47. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A) Disconnect the client from the ventilator and use a manual resuscitation bag B) Perform a quick assessment of the client's condition C) Call the respiratory therapist for help D) Press the alarm re-set button on the ventilator The correct answer is B: Perform a quick assessment of the client''s condition 48. The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? A) "I can't lie in 1 position for more than thirty minutes." B) "I am allergic to shrimp." C) "I suffer from claustrophobia." D) "I developed a severe headache after a spinal tap." The correct answer is B: "I am allergic to shrimp." 49. The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? A) Hold the tube feeding and notify the provider B) Administer the tube feeding as scheduled C) Irrigate the tube with diet cola soda D) Apply intermittent suction to the feeding tube The correct answer is A: Hold the tube feeding and notify the provider 50. To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must A) Apply suction for no more than 10 seconds B) Maintain sterile technique C) Lubricate 3 to 4 inches of the catheter tip D) Withdraw catheter in a circular motion Applying suction for more than 10 seconds 51. An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to A) administer the medication in 2 separate injections B) give the medication in the dorsal gluteal site
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) C) call to get a smaller volume ordered D) check with pharmacy for a liquid form of the medication skip The correct answer is A: administer the medication in 2 separate injections 52. The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to A) enhance absorption of the medication B) ensure that the entire dose of medication is given C) provide more even distribution of the drug D) prevent the drug from tissue irritation Skip The correct answer is D: prevent the drug from tissue irritation 53. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? A) diaphoresis with decreased urinary output B) increased heart rate with increase respirations C) improved respiratory status and increased urinary output D) decreased chest pain and decreased blood pressure The correct answer is C: improved respiratory status and increased urinary output 54. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse’s best response? A) ‖As you urinate more, you will need less medication to control fluid." B) ‖You will have to take this medication for about a year." C) ‖The medication must be continued so the fluid problem is controlled." D) ‖Please talk to your health care provider about medications and treatments." The correct answer is C: "The medication must be continued so the fluid problem is controlled." 55. A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? A) Change in libido, breast enlargement B) Sore throat, fever C) Abdominal pain, nausea, diarrhea D) Dsypnea, nasal congestion The correct answer is B: Sore throat, fever 56. A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic? A) Bruising at the operative site B) Elevated heart rate C) Decreased platelet count D) No bowel movement for 3 days Skip The correct answer is D: No bowel movement for 3 days
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 57. A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values? A) Bleeding time B) Platelet count C) Activated PTT D) Clotting time The correct answer is C: Activated PTT 58. A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate? A) Pulverize all medications to a powdery condition B) Squeeze the tube before using it to break up stagnant liquids C) Cleanse the skin around the tube daily with hydrogen peroxide D) Flush adequately with water before and after using the tube Skip The correct answer is D: Flush adequately with water before and after using the tube 59. The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective? A) ‖We will call the health care provider if the child develops acne." B) ‖Our child should brush and floss carefully after every meal." C) ‖We will skip the next dose if vomiting or fever occur." D) ‖When our child is seizure-free for 6 months, we can stop the medication." The correct answer is B: "Our child should brush and floss carefully after every meal." 60. Although non steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects? A) Urinary incontinence B) Constipation C) Nystagmus D) Occult bleeding The correct answer is D: Occult bleeding 61. The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important? A) Avoid chocolate and cheese B) Take frequent naps C) Take the medication with milk D) Avoid walking without assistance The correct answer is A: Avoid chocolate and cheese 62. A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) A) Cut the child's hair short to remove the nits B) Apply warm soaks to the head twice daily C) Wash the child's linen and clothing in a bleach solution D) Application of pediculicides The correct answer is D: Application of pediculicides 63. The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication? A) Non-steroidal anti-inflammatory drugs B) Cough medicines with guaifenesin C) Histamine blockers D) Laxatives containing magnesium salts The correct answer is A: Non-steroidal anti-inflammatory drugs 64. A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element? A) Sodium B) Potassium C) Phosphate D) Albumin The correct answer is B: Potassium 65. The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take? A) Stop the infusion B) Slow the rate of infusion C) Take vital signs and observe for further deterioration D) Administer Benadryl and continue the infusion The correct answer is A: Stop the infusion 66. Discharge instructions for a client taking alprazolam (Xanax) should include which of the following? A) Sedative hypnotics are effective analgesics B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares C) Caffeine beverages can increase the effect of sedative hypnotics D) Avoidance of excessive exercise and high temperature is recommended The correct answer is B: Sudden cessation of alprazolam 67. A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely? A) Bleeding time B) Hemoglobin and hematocrit C) White blood cells
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) D) Platelets The correct answer is B: Hemoglobin and hematocrit 68. A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin? A) Protamine B) Amicar C) Imferon D) Diltiazem The correct answer is A: Protamine . Protamine binds heparin making it ineffective. 69. The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching? A) "I use a sliding scale to adjust regular insulin to my sugar level." B) "Since my eyesight is so bad, I ask the nurse to fill several syringes." C) "I keep my regular insulin bottle in the refrigerator." D) "I always make sure to shake the NPH bottle hard to mix it well." The correct answer is D: "I always make sure to shake the NPH bottle hard to mix it well." 70. Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? A) Orthostatic hypotension is a common side effect B) Most antipsychotic drugs cause elevated blood pressure C) This provides information on the amount of sodium allowed in the diet D) It will indicate the need to institute anti parkinsonian drugs The correct answer is A: Orthostatic hypotension is a common side effect 71. The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? A) Three apricots B) Medium banana C) Naval orange D) Baked potato The correct answer is D: Baked potato. 72. An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? A) Add a thickening agent to the fluids B) Check the client’s gag reflex C) Feed the client only solid foods D) Increase the rate of intravenous fluids The correct answer is B: Check the client’s gag reflex 73. The nurse is planning care for a client with a CVA. Which of the following measures
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) planned by the nurse would be most effective in preventing skin breakdown? A) Place client in the wheelchair for four hours each day B) Pad the bony prominence C) Reposition every two hours D) Massage reddened bony prominence The correct answer is C: Reposition every two hours 74. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? A) A 79 year-old malnourished client on bed rest B) An obese client who uses a wheelchair C) A client who had 3 incontinent diarrhea stools D) An 80 year-old ambulatory diabetic client The correct answer is A: A 79 year-old malnourished client on bed rest 75. Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? A) Obtain a complete blood count B) Obtain a health and dietary history C) Refer to a provider for a physical examination D) Measure height and weight The correct answer is B: Obtain a health and dietary history 76. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is A) Abdominal x-ray B) Auscultation C) Flushing tube with saline D) Aspiration for gastric contents The correct answer is A: Abdominal x-ray 77. A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client? A) Allow the client to melt ice chips in the mouth B) Provide mints to freshen the breath C) Perform frequent oral care with a tooth sponge D) Swab the mouth with glycerin swabs The correct answer is C: Perform frequent oral care with a tooth sponge 78. The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to A) Exercise doing weight bearing activities B) Exercise to reduce weight C) Avoid exercise activities that increase the risk of fracture D) Exercise to strengthen muscles and thereby protect bones
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) The correct answer is A: Exercise doing weight bearing activities 79. The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction? A) Cheese sandwich with a glass of 2% milk B) Sliced turkey sandwich and canned pineapple C) Cheeseburger and baked potato D) Mushroom pizza and ice cream The correct answer is B: Sliced turkey sandwich and canned pineapple 80. Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? A) All 4 side rails up, wheels locked, bed closest to door B) Lower side rails up, bed facing doorway C) Knees bent, head slightly elevated, bed in lowest position D) Bed in lowest position, wheels locked, place bed against wall The correct answer is D: Bed in lowest position, wheels locked, place bed against wall 81. When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula A) Every four to six hours B) Continuously C) In a bolus D) Every hour The correct answer is B: Continuously 82. The nurse is teaching an 87 year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID A) Glycerine suppositories B) Fiber supplements C) Laxatives D) Stool softeners The correct answer is C: Laxatives 83. A client with diarrhea should avoid which of the following? A) Orange juice B) Tuna C) Eggs D) Macaroni The correct answer is A: Orange juice 84. Which statement best describes the effects of immobility in children? A) Immobility prevents the progression of language and fine motor development B) Immobility in children has similar physical effects to those found in adults C) Children are more susceptible to the effects of immobility than are adults
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) D) Children are likely to have prolonged immobility with subsequent complications The correct answer is B: Immobility in children has similar physical effects to those found in adults 85. A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client’s comfort? A) Increase oral fluid intake B) Encourage visits from family and friends C) Keep conversations short D) Monitor vital signs frequently The correct answer is C: Keep conversations short 86. After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate A) 3 oz. broiled fish, 1 baked potato, . cup canned beets, 1 orange, and milk B) 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple C) A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange The correct answer is D: 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange 87. The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate? A) Decreased carbohydrates and fat B) Decreased sodium and potassium C) Increased potassium and protein D) Increased sodium and fluids The correct answer is B: Decreased sodium and potassium 88. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? A) Presence of blood in stools B) Oozing liquid stool C) Continuous rumbling flatulence D) Absence of bowel movements The correct answer is B: Oozing liquid stool 89. A client in a long term care facility complains of pain. The nurse collects data about the client’s pain. The first step in pain assessment is for the nurse to A) have the client identify coping methods B) get the description of the location and intensity of the pain C) accept the client’s report of pain D) determine the client’s status of pain The correct answer is C: Accept the client''s report of pain 90. An 85 year-old client complains of generalized muscle aches and pains. The first
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) action by the nurse should be A) Assess the severity and location of the pain B) Obtain an order for an analgesic C) Reassure him that this is not unusual for his age D) Encourage him to increase his activity The correct answer is A: Assess the severity and location of the pain 91. A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: A) Visitors must wear a mask and a gown B) There are no special requirements for visitors of clients on contact precautions C) Visitors should wash their hands before and after touching the client D) Visitors The correct answer is C:Visitors should wash their hands before and after touching the client 92. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? A) Institute seizure precautions B) Monitor neurologic status every hour C) Place in respiratory/secretion precautions D) Cefotaxime IV 50 mg/kg/day divided q6h The correct answer is C: Place in respiratory/secretion precautions 93. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls? A) Sensory perceptual alterations related to decreased vision B) Alteration in mobility related to fatigue C) Impaired gas exchange related to retained secretions D) Altered patterns of urinary elimination related to nocturia The correct answer is D: Altered patterns of urinary elimination related to nocturia 94. A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? A) An infant who has been identified to have botulism B) A toddler who ate a number of ibuprofen tablets C) A preschooler who swallowed powdered plant food D) A school aged child who took a handful of vitamins The correct answer is A: An infant who has been identified to have botulism 95. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) A) Apply appropriate signs outside and inside the room B) Apply a mask with a shield if there is a risk of fluid splash C) Wear a gown to change soiled linens from incontinence D) Have gloves on while handling bedpans with feces The correct answer is D: Have gloves on while handling bedpans with feces 96. Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours? A) An infant with a positive culture of stool for Shigella B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii D) A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles on an erythematous base that appear on the skin The correct answer is B: An elderly factory worker with a lab report that is positive for acid-fast bacillus smear 97. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? A) Reverse B) Airborne C) Standard precautions D) Contact The correct answer is D: Contact 98. The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements? A) ‖The treatment requires reapplication in 8 to 10 days." B) ‖Bedding and clothing can be boiled or steamed." C) Children are not to share hats, scarves and combs. D) Nit combs are necessary to comb out nits. The correct answer is C: ―Children are not to share hats, scarves and combs.‖ 99. During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches? A) Wash hands thoroughly before and after client contact B) Wear gloves when in contact with body secretions C) Double glove when in contact with feces or vomitus D) Wear gloves when disposing of contaminated linens The correct answer is A: Wash hands thoroughly before and after client contact 100. A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) A) grilled chicken sandwich and skim milk B) roast beef, mashed potatoes, and green beans C) peanut butter sandwich, banana, and iced tea D) barbecue beef, baked beans, and cole slaw The correct answer is B: roast beef, mashed potatoes, and green beans 101. After an explosion at a factory one of the workers approaches the nurse and says ―I am an unlicensed assistive personnel (UAP) at the local hospital.‖ Which of these tasks should the nurse assign to this worker who wants to help during the care of the wounded workers? A) Get temperatures B) Take blood pressure C) Palpate pulses D) Check alertness The correct answer is C: Palpate pulses 102. Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency? A) An adolescent diagnosed with sepsis 7 days ago with vital signs maintained within low normal B) A middle-aged woman documented to have had an uncomplicated myocardial infarction 4 days ago C) An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis D) A young adult in the second day of treatment for an overdose of acetometaphen The correct answer is D: A young adult in the second day of treatment for an overdose of acetometaphen 103. The mother of a toddler who is being treated for pesticide poisoning asks: ―Why is activated charcoal used? What does it do?‖ What is the nurse's best response? A) ‖Activated charcoal decreases the systemic absorption of the poison from the stomach." B) ‖The charcoal absorbs the poison and forms a compound that doesn't hurt your child." C) ‖This substance helps to get the poison out of the body by the gastrointestinal system." D) ‖The action may bind or inactivate the toxins or irritants that are ingested by children or adults." The correct answer is B: "The charcoal absorbs the poison and forms a compound that does't hurt your child." 104. The nurse is to administer a new medication to a client. Which actions are in the best interest of the client? Verify the order for the medication. Prior to giving the medication the nurse should say A) ‖Please state your name?" Upon entering the room the nurse should ask: B) ‖What is your name? What allergies do you have?" then check the client's name band and allergy band As the room is entered say C) "What is your name?" then check the client's name band Verify the client's allergies on the admission sheet and order.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) D) ―Verify the client's name on the name plate outside the room then as the nurse enters the room ask the client "What is your first, middle and last name?" The correct answer is B: Upon entering the room the nurse should ask: "What is your name? What allergies do you have?" then check the client''s name band and allergy band 105. Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition? A) Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV) B) A positive purified protein derivative with an abnormal chest x-ray C) A tentative diagnosis of viral pneumonia with productive brown sputum D) Advanced carcinoma of the lung with hemoptasis The correct answer is B: A positive purified protein derivative with an abnormal chest xray 106. A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include during the instructions to the client is which of these statements? A) In the initial 48 hours avoid contact with children and pregnant women, and after urination or defecation flush the commode twice. B) Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose, do so in the toilet and flush it twice. C) Your family can use the same bathroom that you use without any special precautions. D) Drink plenty of water and empty your bladder often during the initial 3 days of therapy. The correct answer is A: ―In the initial 48 hours avoid contact with children and pregnant women, and after urination or defecation flush the commode twice.‖ 107. Which approach is the best way to prevent infections when providing care to clients in the home setting? A) Hand washing before and after examination of clients B) Wearing non powdered latex free gloves to examine the client C) Using a barrier between the client's furniture and the nurse's bag D) Wearing a mask with a shield during any eye/mouth/nose examination The correct answer is A: Hand washing 108. A 10 year-old child has a history of epilepsy with tonic-clonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the most important action during the seizure would be to A) Move any chairs or desks at least 3 feet away from the child B) Note the sequence of movements with the time lapse of the event C) Provide privacy as much as possible to minimize fighting the other children D) Place the hands or a folded blanket under the head of the child The correct answer is D: Place the hands or a folded blanket under the head of the child 109. A mother calls the hospital hot line and is connected to the triage nurse. The mother proclaims: ―I found my child with odd stuff coming from the mouth and an unmarked bottle nearby.‖ Which of these
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) comments would be the best for the nurse to ask the mother to determine if the child has swallowed a corrosive substance? A) Ask the child if the mouth is burning or throat pain is present B) Take the child’s pulse at the wrist and see if the child is has trouble breathing lying flat. C) What color is the child’s lips and nails and has the child voided today? D) Has the child had vomiting or diarrhea or stomach cramps yet? The correct answer is A: ―Ask the child if the mouth is burning or throat pain is present‖ 110. The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement? A) Have the client cough into a tissue and dispose in a separate bag B) Instruct the client to cover the mouth with a tissue when coughing C) Reinforce for all to wash their hands before and after entering the room D) Place client in a negative pressure private room and have all who enter the room use masks with shields The correct answer is D: Place client in a negative pressure private room and have all who enter the room use masks with shields 111. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN? A) Test a stool specimen for occult blood B) Assist with the ambulation of a client with a chest tube C) Irrigate and redress a leg wound D) Admit a client from the emergency room The correct answer is C: Irrigate and redress a leg wound 112. When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because A) Normal patterns of behavior may be labeled as deviant, immoral, or insane B) The meaning of the client's behavior can be derived from conventional wisdom C) Personal values will guide the interaction between persons from 2 cultures D) The nurse should rely on her knowledge of different developmental mental stages The correct answer is A: Normal patterns of behavior may be labeled as deviant, immoral, or insane 113. The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client? A) Assign an RN to provide total care of the client B) Assign a nursing assistant to help the client with self-care activities C) Delegate complete care to an unlicensed assistive personnel D) Supervise a nursing assistant for skin care The correct answer is D: Supervise a nursing assistant for skin care. 114. The nursing student is discussing with a preceptor the delegation of tasks to an
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process? A) Assist a client post cerebral vascular accident to ambulate B) Feed a 2 year-old in balanced skeletal traction C) Care for a client with discharge orders D) Collect a sputum specimen for acid fast bacillus The correct answer is C: Care for a client with discharge orders 115. After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can’t do anything that pleases him. I’m not going in there again." The nurse should respond by saying A) ‖He has a lot of problems. You need to have patience with him." B) ‖I will talk with him and try to figure out what to do." C) ‖He is scared and taking it out on you. Let's talk to figure out what to do." D) ‖Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day." The correct answer is C: "He is scared and taking it out on you. Let''s talk to figure out what to do." 116. A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client’s mental status and adjustment. The appropriate response of the nurse should be which of these statements? A) I am sorry. Referral information can only be provided by the client’s health care providers. B) ―I can never give any information out by telephone. How do I know who you are?" C) Since this is a referral, I can give you the this information. D) I need to get the client’s written consent before I release any information to you. The correct answer is D: I need to get the client’s written consent before I release any information to you. 117. A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states ―I don’t think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects.‖ The nurse should understand that A) A referral is needed to the psychiatrist who is to provide the client with answers B) The client has a right to know about the prescribed medications C) Such education is an independent decision of the individual nurse whether or not to teach clients about their medications D) Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects The correct answer is B: The client has a right to know about the prescribed medications 118. Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time? A) ‖Have the client sit on the side of the bed for at least 2 minutes before helping him
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) stand." B) ‖If the client is dizzy on standing, ask him to take some deep breaths." C) ‖Assist the client to the bathroom at least twice on this shift." D) ‖After you assist him to the chair, let me know how he feels." The correct answer is A: "Have the client sit on the side of the bed for at least 2 minutes before helping him stand." 119. The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client A) Has had a change in respiratory rate by an increase of 2 breaths B) Has had a change in heart rate by an increase of 10 beats C) Was minimally responsive to voice and touch D) Has had a blood pressure change by a drop in 8 mmHg systolic The correct answer is C: Was minimally responsive to voice and touch 120. A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is A) ‖I must document and report any information." B) ‖I can’t make such a promise." C) ‖That depends on what you tell me." D) ‖I must report everything to the treatment team." The correct answer is B: "I can’t make such a promise." 121. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)? A) Be with a client who self-administers insulin B) Cleanse and dress a small decubitus ulcer C) Monitor a client's response to passive range of motion exercises D) Apply and care for a client's rectal pouch The correct answer is D: Apply and care for a client''s rectal pouch 122. A client asks the nurse to call the police and states: ―I need to report that I am being abused by a nurse.‖ The nurse should first A) Focus on reality orientation to place and person B) Assist with the report of the client’s complaint to the police C) Obtain more details of the client’s claim of abuse D) Document the statement on the client’s chart with a report to the manager The correct answer is C: Obtain more details of the client’s claim of abuse 123. A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with A) A Dopamine drip IV with vital signs monitored every 5 minutes B) A myocardial infarction that is free from pain and dysrhythmias C) A tracheotomy of 24 hours in some respiratory distress
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) D) A pacemaker inserted this morning with intermittent capture The correct answer is B: A myocardial infarction that is free from pain and dysrhythmias 124. An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions? A) ‖How long have you been a UAP and what units you have worked on?" B) ‖What type of care do you give on the surgical unit and what ages of clients?" C) ―What is your comfort level in caring for children and at what ages?" D) ‖Have you reviewed the list of expected skills you might need on this unit?" The correct answer is D: "Have you reviewed the list of expected skills you might need on this unit?" 125. A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse’s response should be to A) Ask to not be assigned to this client or to work on another unit B) Tell the client that such behavior is inappropriate C) Inform the client that hospital policy prohibits staff to date clients D) Discuss the boundaries of the therapeutic relationship with the client The correct answer is D: Discuss the boundaries of the relationship with the client 126. A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)? A) To observe the type and amount of nasogastric tube drainage B) Monitor the client for nausea or other complications C) Irrigate the nasogastric tube with the ordered irrigate D) Perform nostril and mouth care The correct answer is D: Perform nostril and mouth care 127. The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)? A) Test blood sugar every 2 hours by accu check B) Review with family and client signs of hyperglycemia C) Monitor for mental status changes D) Check skin condition of lower extremities Review Information: The correct answer is A: Test blood sugar every 2 hours by accucheck 128. A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP? A) A 76-year-old client with severe depression B) A middle-aged client with an obsessive compulsive disorder C) A adolescent with dehydration and anorexia D) A young adult who is a heroin addict in withdrawal with hallucinations The correct answer is B: A middle-aged client with an obsessive compulsive disorder
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 129. The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees F for a post surgical client. The nurse checks on the client’s condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP? A) Encourage oral fluids for the temperature elevation B) Check temperature 15 minutes after hot liquids are taken C) Ask the client to drink only cold water and juices D) Chart this temperature elevation on the flow sheet The correct answer is B: Check temperature 15 minutes after hot liquids are taken 130. A client continuously calls out to the nursing staff when anyone passes the client’s door and asks them to do something in the room. The best response by the charge nurse would be to A) Keep the client’s room door cracked to minimize the distractions B) Assign 1 of the nursing staff to visit the client regularly C) Reassure the client that 1 staff person will check frequently if the client needs anything D) Arrange for each staff member to go into the client’s room to check on needs every hour on the hour The correct answer is B: Assign 1 of the nursing staff to visit the client regularly 131. A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses concern that the client seems depressed. The nurse should initially focus assessment by using which approach? A) The results of a standardized tool that measures depression B) Observation of affect and behavior C) Inquiry about use of alcohol D) Family history of emotional problems or mental illness The correct answer is B: Observation of affect and behavior 132. A mother with a Roman Catholic belief has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to do? A) The refusal of any treatment for self and the neonate until she talks to a reader B) The placement of a rosary necklace around the neonate's neck and not to remove it unless absolutely necessary C) Arrange for a church elder to be at the emergency department when the ambulance arrives so a "laying on hands" can be done D) Pour fluid over the forehead backwards towards the back of the head and say "I baptize you in the name of the father, the son and the holy spirit. Amen." The correct answer is D: Pour fluid over the forehead backwards towards the back of the head and say "I baptize you in the name of the father, the son and the holy spirit. Amen." 133. An American Indian chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The attending nurse tells a colleague "I
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) wonder if he has any idea how ridiculous he looks -- he's a grown man!" The nurse's response is an example of A) Discrimination B) Stereotyping C) Ethnocentrism D) Prejudice The correct answer is D: Prejudice 134. A client expresses anger when the call light is not answered within 5 minutes. The client demanded a blanket. The best response for the nurse to make is A) "I apologize for the delay. I was involved in an emergency." B) "Let's talk. Why are you upset about this?" C) "I am surprised that you are upset. The request could have waited a few more minutes." D) "I see this is frustrating for you. I have a few minutes so let's talk." The correct answer is D: "I see this is frustrating for you. I have a few minutes so let''s talk." 135. An elderly client who lives in a retirement community is admitted with these behaviors as reported by the daughter: absence in the daily senior group activity, missing the weekly card games, a change in calling the daughter from daily to once a week, and the client's tomato garden is overgrown with weeds. The nurse should assign this client to a room with which one of these clients? A) An adolescent who was admitted the day before with acute situational depression B) A middle aged person who has been on the unit for 72 hours with a dysthymia C) An elderly person who was admitted 3 hours ago with cycothymia D) A young adult who was admitted 24 hours ago for detoxification The correct answer is B: A middle aged person who has been on the unit for 72 hours with a dysthymia 136. A client diagnosed with anorexia nervosa states after lunch, "I shouldn’t have eaten all of that sandwich, I don’t know why I ate it, I wasn’t hungry." The client’s comments indicate that the client is likely experiencing A) Guilt B) Bloating C) Anxiety D) Fear The correct answer is A: Guilt 137. A 65-year-old Catholic Hispanic-Latino client with prostate cancer adamantly refuses pain medication because the client believes that suffering is part of life. The client states ―everyone’s life is in God's hands.‖ The next action for the nurse to take is to A) Report the situation to the health care provider B) Discuss the situation with the client's family C) Ask the client if talking with a priest would be desired
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) D) Document the situation on the notes The correct answer is C: Ask the client if talking with a priest would be desired 138. A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission, the nurse finds a bottle of assorted pills in the client’s drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be A) "These pills aren’t antacids since they are all different." B) "Some teenagers use pills to lose weight." C) "Tell me about your week prior to being admitted." D) "Are you taking pills to change your weight?" The correct answer is C: "Tell me about your week prior to being admitted." 139. A client who has a belief based in Hinduism is nearing death. The nurse should plan for which action? A) After death a Hindu priest will pour water into the mouth of the client and tie a thread around the client's wrist B) The elders may be with the client during the process of the client dying and no last rites are given C) The family must be with the client during the process of dying and be the only ones to wash the body after death D) The body is ritually cleansed and burial is to be as soon as possible after the death occurs The correct answer is A: After death a Hindu priest will pour water into the mouth of the client and tie a thread around the client''s wrist 140. An explosion has occurred at a high school for children with special needs and severe developmental delays. One of the students accompanied with a parent is seen at a community health center a day later. After the initial assessment the nurse concludes that the student appears to be in a crisis state. Which of these interventions based on crisis intervention principles is appropriate to do next? A) Help the student to identify a specific problem B) Ask the parent to identify the major problem C) Ask the student to think of different alternatives D) Examine with the parent a variety of options The correct answer is B: Ask the parent to identify the major problem 141. Which statement made by a client to the admitting nurse suggests that the client is experiencing a manic episode? A) "I think all children should have their heads shaved." B) "I have been restricted in thought and harmed." C) "I have powers to get you whatever you wish, no matter the cost." D) "I think all of my contacts last week have attempted to poison me." Review Information: The correct answer is C: "I have powers to get you whatever you wish, no matter the cost."
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 142. A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland." The nurse would document this behavior as A) Perseveration B) Circumstantiality C) Neologisms D) Flight of ideas The correct answer is D: Flight of ideas 143. During the change-of-shift report the assigned nurse notes a Catholic client is scheduled to be admitted for the delivery of a ninth child. Which comment stated angrily to a colleague by this nurse indicates an attitude of prejudice? A) "I wonder who is paying for this trip to the hospital?" B) "I think she needs to go to the city hospital." C) "All those people indulge in large families!" D) "Doesn't she know there's such a thing as birth control?" The correct answer is D: "Doesn't she know there''s such a thing as birth control?" 144. Which of these statements by the nurse reflects the best use of therapeutic interaction techniques? A) ‖You look upset. Would you like to talk about it?" B) ‖I’d like to know more about your family. Tell me about them." C) ‖I understand that you lost your partner. I don't think I could go on if that happened to me." D) ‖You look very sad. How long have you been this way?" The correct answer is A: "You look upset. Would you like to talk about it?" 145. A nurse in the emergency department suspects domestic violence as the cause of a client's injuries. What action should the nurse take first? A) Ask client if there are any old injuries also present B) Interview the client without the persons who came with the client C) Gain client's trust by not being hurried during the intake process D) Photograph the specific injuries in question The correct answer is B: Interview the client without the persons who came with the client 146. Which of these findings would indicate that the nurse-client relationship has passed from the orientation phase to the working phase? The client A) Has revitalized a relationship with her family to help cope with the death of a daughter B) Had recognized regressive behavior as a defense mechanism C) Expresses a desire to be cared for and pampered D) Recognizes feelings with appropriate expression of feelings The correct answer is D: Recognizes feelings with appropriate expression of feelings 147. A client who is thought to be homeless is brought to the emergency department by police. The client is unkempt, has difficulty concentrating, is unable to sit still and speaks
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) in a loud tone of voice. Which of these actions is the appropriate nursing intervention for the client at this time? A) Allow the client to randomly move about the holding area until a hospital room is available B) Engage the client in an activity that requires focus and individual effort C) Isolate the client in a secure room until control is regained by the client D) Locate a room that has minimal stimulation outside of it for admission process The correct answer is D: Locate a room that has minimal stimulation outside of it for admission process 148. A 2 day-old child with spina bifida and meningomyocele is in the intensive care unit after the initial surgery. As the nurse accompanies the grandparents for a first visit, which response should the nurse anticipate of the grandparents? A) Depression B) Anger C) Frustration D) Disbelief The correct answer is D: Disbelief 149. Which statement by the client during the initial assessment in the the emergency department is most indicative for suspected domestic violence? A) ‖I am determined to leave my house in a week." B) ‖No one else in the family has been treated like this." C) ‖I have only been married for 2 months." D) ‖I have tried leaving, but have always gone back." The correct answer is D: "I have tried leaving, but have always gone back." 150. A nurse states: "I dislike caring for African-American clients because they are all so hostile." The nurse's statement is an example of A) Prejudice B) Discrimination C) Stereotyping D) Racism The correct answer is C: Stereotyping 151. Which statement made by a nurse about the goal of total quality management or continuous quality improvement in a health care setting is correct? A) ―It is to observe reactive service and product problem solving." B) Improvement of the processes in a proactive, preventive mode is paramount. C) A chart audits to finds common errors in practice and outcomes associated with goals. D) A flow chart to organize daily tasks is critical to the initial stages. The correct answer is B: Improvement of the processes in a proactive, preventive mode is paramount. 152. The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) staff are invited to participate in the study if they wish. This affirms the ethical principle of A) Anonymity B) Beneficence C) Justice D) Autonomy The correct answer is D: Autonomy 153. When teaching a client about the side effects of fluoxetine (Prozac), which of the following will be included? A) Tachycardia blurred vision, hypotension, anorexia B) Orthostatic hypotension, vertigo, reactions to tyramine rich foods C) Diarrhea, dry mouth, weight loss, reduced libido D) Photosensitivity, seizures, edema, hyperglycemia The correct answer is C: Diarrhea, dry mouth, weight loss, reduced libido 154. The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is A) A firm touch to the trapezius muscle or arm B) Pinching any body part C) Sternal rub D) Gentle pressure on eye orbit The correct answer is D: Gentle pressure on eye orbit 155. The nurse is teaching about non steroidal anti-inflammatory drugs to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions? A) Reporting joint stiffness in the morning B) Taking the medication 1 hour before or 2 hours after meals C) Using alcohol in moderation unless driving D) Continuing to take aspirin for short term relief The correct answer is B: Taking the medication 1 hour before or 2 hours after meals 156. A client taking isoniazide (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these? A) Double vision and visual halos B) Extremity tingling and numbness C) Confusion and lightheadedness D) Sensitivity of sunlight The correct answer is B: Extremity tingling and numbness 157. The nurse admits a 2 year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure? A) "He has been taking long naps for a week." B) "He has had an ear infection for the past 2 days."
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) C) "He has been eating more red meat lately." D) "He seems to be going to the bathroom more frequently." The correct answer is B: "He has had an ear infection for the past 2 days." 158. A client is receiving Total Parenteral Nutrition (TPN) via Hickman catheter. The catheter accidentally becomes dislodged from the site. Which action by the nurse should take priority? A) Check that the catheter tip is intact B) Apply a pressure dressing to the site C) Monitor respiratory status D) Assess for mental status changes The correct answer is B: Apply a pressure dressing to the site 159. An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When the nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The nurse understands that which of the following is true in regards to giving immunizations to this child? A) Live vaccines are withheld in children with renal chronic illness B) The MMR vaccine should be given now, prior to the transplant C) An inactivated form of the vaccine can be given at any time D) The risk of vaccine side effects precludes giving the vaccine The correct answer is B: The MMR vaccine should be given now, prior to the transplant 160. The nurse is preparing to administer a tube feeding to a post-operative client. To accurately assess for a gastrostomy tube placement, the priority is to A) Auscultate the abdomen while instilling 10 cc of air into the tube B) Place the end of the tube in water to check for air bubbles C) Retract the tube several inches to check for resistance D) Measure the length of tubing from nose to epigastrium The correct answer is A: Auscultate the abdomen while instilling 10 cc of air into the tube
1. A client in the second stage of labor has a fully dilated cervix and says that she feels like she has to move her bowels. What should the nurse respond to the client? A. ―That means it is time for you to start pushing.‖ 2. The nurse is assessing a client for testing to diagnose meningitis. Which finding suggests to the nurse that the client is experiencing this health problem? A. Negative Kernig sign 3. A 59 yr old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client’s condition? A. He is in a coma, and has a very poor prognosis
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 4. A client who has a prescription for fluid restriction asks the nurse for a mid-afternoon snack. What is the best snack to bring to the client A. Custard 5. A client arrives in the ED with slurred speech and right-sided weakness A. Onset of symptoms 6. An elderly client is admitted with an enlarged liver and jugular vein distention. The nurse realizes these manifestations are most likely associated with which disease process? A. Right heart failure. 7. A client experiencing pink frothy sputum is having a brain natriuretic peptide level (BNP) drawn. How will this laboratory test help guide the care this client needs at this time? A. The BNP level will be low if the cause for the pink frothy sputum is respiratory failure. 8. At a community health fair, a 50 yr old woman tells the nurse she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond? A. Ask the woman if she also performs monthly breast self-exams 9. The nurse is developing a teaching plan for a client who was recently diagnosed with pernicious anemiaand requires vitamin B12 replacement therapy. Which precaution is most important for the nurse to include in the clients plan of care. A. Schedule daily rest periods to minimize fatigue
10. The community mental health nurse is planning to visit 4 clients with schizophrenia..see first A. The father who took his children from school because aliens were after them 11. The wife of a client with terminal cancer gives the nurse a copy of her husband’s living will. What action should the nurse take? A. Notify the healthcare provider of the client’s wishes. 12. An adolescent client is recovering from a spinal cord injury sustained from a motor vehicle crash. The client’s mother has been at the bedside since admission and has stopped going to work and caring for other family members. Which action should the nurse take at this time? A. Spend time with the mother to find out what her needs are. 13. While performing a physical examination of a 10-month-old infant, the nurse notes raw moist weeping macules and papules of skin on the child’s genitals, upper thighs and bottom. How should the nurse document this finding? A. Diaper dermatitis 14. Which assessment finding should indicate to the nurse that a client with arterial HTN is experiencing a cardiac complication? A. Complaints of shortness of breath on exertion 15. In preparing to administer an intravenous medication, the nurse notes that the drug is listed in drug reference guide as being incompatible with the currently infusing intravenous solution of
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) Ringer’s Lactate. What action should the nurse take? A. Flush the line with a compatible solution before and after administering the medication
16. A 7-year-old child is admitted to the hospital with acute glomerulonephritis (AGN). When obtaining the nursing history, which finding should the nurse expect to obtain
A. A recent strep throat infection 17. A client with a fractured femur is placed in traction to immobilize the fracture. When transporting this client to another room, how should the nurse handle the traction? A. Leave the weights in place for the full duration of the transport. 18. A client recovering from a spinal cord injury is experiencing a spastic neurogenic bladder. Which action should the nurse teach the client to stimulate reflex voiding? A. The antipyretic medication was effective. 19. A college student who is Dx with a vaginal infection and vulva irritation describes the vaginal discharge as having a ―cottage-cheese‖ appearance. Which prescription should the nurse implement first? A. Instill the first dose of nystatin (Mycostatin) vaginally per applicator 20. A client with an overactive bladder receives a prescription Oxybutynin (Ditropan) an anticholinergic agent. Which information should the nurse include in this client teaching plan. A. Sugar free hard candies may relieve dry mouth 21. Beginning with the vena cava, what is the normal sequence of blood circulation through the heart (arrange from entry of the heart on top to exit of the heart on the bottom) A. Right atrium, tricuspid valve, right ventricle, pulmonary semilunar valve, left atrium, mitral valve, left ventricle, aortic semilunar valve 22. A client with type 2 diabetes mellitus is prescribed daily insulin injections however has limited manual dexterity. What can be done to ensure the client’s compliance with this medication? A. Recommend that insulin be prescribed through the use of a pen. 23. The healthcare provider prescribed triazolam (Halcion) 500 mcg for a client with insomnia. The pharmacy supplies Halcion in 0.25 mg tablets. How many tablets should the nurse administer? (Enter numeric value only.) A. 2 24. An 18-month-old pediatric client with neuroblastoma is crying. The nurse realizes that the source of this crying is probably because A. The client is in pain. 25. A client in acute renal failure has a serum potassium of 7.5 mEq/L. Based on this finding the nurse should anticipate implementing which action? A. Administer a retention enema of Kayexalate
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 26. A female client who is receiving chemotherapy asks the nurse if she can have a fresh green salad because she is nauseated. Which response should the nurse provide. A. Canned vegetables are recommended while taking chemotherapy 27. The nurse is assessing the emotional status of a client with Parkinson’s disease. Which client finding is most helpful in planning goals to meet the client’s emotional needs A. Cries frequently during the interview 28. A middle-aged female client is admitted to the hospital with a medical diagnosis of acute renal failure (ARF). The healthcare provider informs her that her treatment program will include hemodialysis. Which response demonstrates that this client understands what will occur with hemodialysis? A. ―Using the kidney machine every few days will help rest my kidneys so they can function again.‖ 29. The psychiatric treatment team is considering a weekend pass with family for a client being treated for major depression. Why is the treatment team considering the pass for the client? A. Support the client’s return to usual at-home activities. 30. The nurse manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit? A. A 35 year-old with Lupus erythematosus 31. The health care provider telephones the nurse and provides a verbal prescription for a client’s persistentcough and pulmonary wheezing. The prescription includes a chest x-ray and antibiotic and a nebulizer treatment now and PRN, in what order should these interventions be implemented? (Arrange the first action on top, and the last action on the bottom) A. Read prescriptions back to the healthcare provider Enter the verbal prescription in the electronic medical record Administer the PRN nebulizer breathing treatment Prepare the client for transport to radiology for a chest x-ray 32. What nursing intervention is particularly indicated for the second stage of labor A. Assisting the client to push effectively so that expulsion of the fetus can be achieved
33. The mother of a 5-year-old boy calls the emergency room and reports that a pot of hot soup was pulled off the stove onto her child’s right arm and leg. What should the nurse tell this mother to do first? A. Wrap the child in a blanket and bring him to the hospital immediately. 34. A client, receiving an inhaled corticosteroid medication for asthma, has no change in peak flow meter rates. What does this finding suggest to the nurse? A. The dose of the medication might need to be adjusted.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 35. A nurse is teaching a client postoperative breathing techniques using an incentive spirometer (IS). What should the nurse encourage this client to do to maintain sustained maximal inspiration? A. Inspire deeply and slowly over 3 to 5 seconds 36. Based on the Braden Risk Assessment Scales, Which client is at highest risk? A. A male who is aphasic and experiencing bladder incontinence 37. A newborn is apneic for 20 seconds. What action should the nurse implement A. Stimulate by gently rubbing infant’s trunk 38. The nurse is completing a neurological assessment. Which observation indicates an abnormal pupil response A. When shining the light into the right eye, the left pupil does not constrict 40. A nurse is caring for a client with a diagnosis of acute renal failure who complains of shortness of breath, weakness, headache, and swelling of the lower legs and feet. What nursing intervention should be completed immediately? A. Elevate the head of the bed at least 45 degrees. 41. The community health nurse is planning an education program to present to the women and children who visit the local WIC program intake office. Which topic would be applicable for the nurse to prepare for these individuals? A. Approaches to prevent dental caries in children. 42. The nurse plans to educate a client about the purpose for taking the prescribed antipsychotic medication clozapine (Clozaril). Which statement should the nurse provide? A. ―the medication will help you think more clearly‖ 43. Prior to removing surgical wound staples, what assessment is most important for the nurse to complete? A. Determine the level of incisional pain 44. The nurse manager is concerned about the number of falls that have occurred on the unit in the last month. Which action is most likely to decrease the number of falls A. Obtain the evidence based practice guidelines for falls prevention 45. A client with acute low back pain reports pain radiating down the buttock to below the knee. Initial nursing actions should be based on which interpretation of these symptoms? A. This pain is along the path of the sciatic nerve. 46. A client is prescribed bed rest as part of treatment for a deep vein thrombosis of the lower extremity. The nurse plans for active range of motion exercises to be performed with the client 3
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) times a day. Which nursing diagnosis will the intervention of active range of motion exercisessupport? A. Potential for impaired mobility 47. A male client with diabetes mellitus takes Novolin 70/30 insulin before meals and azithromycin (Zithromax) PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, he tells her that he took his insulin but forgot to take his daily dose of the Zithromax an hour before breakfast as instructed. Action? A. Instruct the client to eat his breakfast and take the Zithromax two hours after eating 48. What instruction is most important for the nurse to provide a female client who has just been diagnosed with trichomoniasis? A. Treat sexual partner(s) concurrently 49. Which technique should the school nurse use to assess a group of children with pediculosis capitis (headlice) A. Inspect the hair shaft for white…… 50. The healthcare provider prescribes diltiazem (Cardizem ) for a child with hypertension who weighs 66 pounds. Based on the recommended dose of 3.5 mg/kg/day, how many mg should the child receive per day A. 105
51. The nurse is assigning rooms for four clients, each newly diagnosed and being admitted to the acute neuro unit for treatment. The client with which diagnosis should be assigned the only private room available? A. Bacterial meningitis. 52. A client is prescribed bed rest with bathroom privileges. What would the nurse instruct unlicensed assistive personnel (UAP) when providing morning care to the client? A. Ambulate the client to use the commode to void and return to the bed. 53. A primagravida at term comes to the prenatal clinical and tells the nurse that she is having contractions every 5 minutes. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the client’s contractions are 7 to 15 seconds with mild intensity by palpation. Action? A. Send the client home and instruct her to call the clinic when her contractions occur 5 minutes apart for one hour 54. A nurse assesses a client’s care after receiving a report from the practical nurse, who is leaving the unit.The PN report that the clients’ dressing was changes, and the dressing change and wound appearance were documented in the nurses’ note. The nurse later observes that the date on the clients dressing is from the previous day and was initialed by the nurse who cared for the client the previous day, What action should the nurse take?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) A. Confirm the finding with the charge nurse before completing and documenting the dressing change 55. One year after being diagnosed with Pneumocystic carinii pneumonia, a client is admitted with respiratory failure. Respirations are shallow with periods of apnea. After the HCP delivers a grim prognosis to the client’s family, which intervention should the nurse implement first A. Clarify client’s end of life wishes 56. A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take? A. Perform a sterile vaginal exam. 57. A client who is 6 weeks postpartum is diagnosed with postpartum psychosis. What manifestations of this disorder will the nurse expect to assess in the client? A. Hears voices saying the baby is a mass murderer 58. Which instruction should the nurse provide to an elderly client taking an ACE inhibitor and a calcium channel blocker? A. Change positions slowly 59. A client with Bells’ palsy is at risk for impaired nutrition, which action should nurse include in the clients plan of care? face
A. Teach the client to chew food on the unaffected side of the
60. When preparing to start change-of-shift report, the charge nurse observes an unlicensed assistive personnel (UAP) walking in the hallway with a urine specimen that is not covered. After telling the UAP to cover the specimen, what intervention should the charge nurse implement A. Review infection control guidelines with the UAP at the next opportunity 61. In monitoring a client’s respiratory status, which symptom is characteristic of early acute (adult) respiratory distress syndrome (ARDS) A. Increased respiratory rate 62. A client’s serum potassium test level is 6 mEq/L. The laboratory indicates, ―Specimen is hemolyzed.‖ What action should the nurse take A. Draw a new blood specimen 63. A client who developed Syndrome of Inappropriate Antidiuretic Hormone (SIADH) associated with small cell carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the healthcare provider? A. Muscle cramping. 64. In determining the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition? A. Orthopnea.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 65. A male client with HIV, who is being admitted to a healthcare facility, tells the nurse that he is concerned about his right to have access to his records and explanations regarding his treatment and the cost of such treatment. Which resource should guide the nurse’s response to this client? A. The Patient’s Bill of Rights. 66. The nurse is identifying a strategy to communicate with a client recovering from a left-sided cerebrovascular accident. The client is righthanded and is aphasic. Which strategy will be the best for the nurse to use? A. Provide flip cards with pictures that describe commonly used words, phrases, and activities. 67. The nurse who routinely works on a medical-surgical unit has been asked to help staff another client care area. The nurse is cross-trained in hemodialysis and orthopedic nursing. Which care area would be the best for the nurse to support client care needs? A. Renal transplant unit. 68. Assessment findings of a 3-hr old newborn include: axillary temperature of 97.7, HR of 140 with a soft murmur, and irregular RR 42. Based on these findings; action?
A. Record the findings on the flow sheet
69. A client admitted to the hospital for depression is escorted to a private room. Prior to leaving the room, what intervention is most important for the nurse to implement? . A. Search all personal belongings 70. An experienced nurse tells the nurse manager that working with a new graduate is impossible because the new grad will not listen to suggestions. The new grad comes to the nurse manager describing the senior nurses’ attitude as challenging and offensive. Action best for NM to take? A. Ask the nurses to meet with the nurse manager to identify ways of working together 71. A new employee in a long term care facility for clients with Alzheimer’s tells the nurse that an elderly male client constantly asks for his mother who died many years ago. The UAP asks the nurse for advice on how to respond to the client. Which response should the nurse provide? A. Remind the client that his mother died many years ago and change the subject. 72. A client with metastatic cancer and a very limited prognosis is being discharged from the hospital, when developing a plan for this client, which goal has the highest priority?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) A. Intake of adequate nutrients will be maintained. 73. A nurse is observing the appearance of an older clients eyes. Which finding warrants immediate intervention? A. conjunctival sacs are pale 74. A client with type 2 diabetes mellitus (DM) receives a new prescription for sitagliptin (januvia) In providing client teaching, the nurse should emphasize the importance of reporting which problem to the healthcare provider immediately? A. Upper respiratory infection 76. Which action should the nurse implement to reduce a clients risk for nosocomial infection A. Replace continuous tube feeding bag and tubing at least daily 77. During the admission interview, the nurse leader learns that a newly admitted adult client has a six month history if recurring somatic pain. Which problem is most important for the nurse to further explore with the client . A. Feelings of depression 78. An older male adult resident of an extended care facility receives a prescription for diphenhydramine (Benadryl) 25 mg PO to treat generalized pruritis. Two hours after administration of the drug, he continues to experience itching, is confused, and has an unsteady gait. Which actions should the nurse implement first A. Place the client on fall precautions 79. A female resident of a long-term care facility is being admitted to the medical department. The client has a fractured humerous and methicillin-resistant staphylococcus aureus (MRSA). Which room should the charge nurse assign this client A. A semi-private room with another client who also has MRSA 80. When assessing the oral temperature of an adult client at 6:00 pm, the nurse notes that the client’s temperature at 6:00 am was 97.2, and is now 98.8. Which intervention should the nurse implement? A. Document this temperature variation on the graphic sheet. 81. It would be of greatest benefit for the client with which problem related to diabetes mellitus to change from the use of insulin syringes to using an insulin pen for medication administration? A. Diminished dexterity due to finger paresthesias. 82. In planning care for a client with a nursing diagnosis of ―Impaired mobility‖, the nurse instructs the unlicensed assistive personnel (UAP) to assist the client with ambulation. Because the healthcare provider has prescribed bed rest for the client, what action should the nurse take? A. Change the planned interventions to include range of motion exercises rather than ambulation. 83. When assigning an unlicensed assistive personnel (UAP) to assist a client with personal care, which client information is most important for the nurse to provide the UAP? A. Prescribed activity level.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 84. 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? A. Postpartum psychosis. 85. After repositioning the endotracheal tube on a client being mechanically ventilated which action would the nurse make? A. Confirm placement with a chest x-ray. 86. A male client is prescribed enalapril maleate (Vasotec) as treatment for hypertension. What will the nurse include when instructing the client about this medication? A. It can cause male impotence. 87. A client being treated for sickle cell disease wants to have children. The spouse has been identified as a carrier of the disease. What type of counseling should the client receive about having children? A. All children have a 50% chance of being affected by the disease. 88. Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock? A. Ineffective tissue perfusion 89. The nurse offers diet teaching to a female college student who was Dx with iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet? A. Combine several legumes and grains such as beans and rice to form complete proteins 90. The nurse is triaging clients from a train wreck. A client has multiple open wounds, a BP of 90/50, and Pulse of 112. Which triage tag color should the nurse place on this client? A. Red
91. Which action should the nurse include in the plan of care for a client who is receiving acyclovir (Zovirax) IV for treatment of herpes zoster (shingles)? A. Monitor serum creatinine levels 92. A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+ pitting edema around the ankles. It is most important for the nurse to obtain what additional client data? A. Breath sounds 93. A male adult client is transferred to a psychiatric facility following release from the hospital for treatment of a self-inflicted gunshot wound. In attempting to develop a therapeutic relationship with the client, which information is most important? A. The nurses’ feelings about this client
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 94. Which client requires careful nursing assessment for signs and symptoms of hypermagnesemia? A. A middle-aged male client in renal failure following an unsuccessful kidney transplant 95. When analyzing objective data obtained during a physical assessment, what action should the nurse perform first? A. Compare the data against established norms 96. The nurse is assessing the reflexes of a 35 year old male client who came to the clinic for his annual physical exam. When the nurse strikes the patellar tendon, there is no response. What action should the nurse take next? A. Record the patellar reflex as a zero 97. A charge nurse overhears a practical nurse (PN) tell unlicensed Assistive personnel (UAP) to apply sequential Compression devices to the legs of a postoperative client. What action should the charge nurse take? A. Advise that the PN should apply the devices rather than assign the work to the UAP
98. The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non English speaking client. The client gives verbal consent and the healthcare provider ?????? ?????? the nurse to witness the signature on the consent form. The client and interpreter then speak together in the foreign language for an additional (3?) minutes, until the interpreter (?????) ―she says it is OK‖, What action should the nurse take now? A. Have the interpreter cosign the consent form to verify client understanding
99. The healthcare provider prescribes several medications for a client diagnosed with myasthenia gravis (MG) Which medication would the nurse expect to use to differentiate a myasthenic crisis from acholinergic crisis? A. Edrophonium (Tensilon) 100. The healthcare provider is working with a client who was recently diagnosed with asthma. Which statement by the client indicates to the nurse that further teaching is needed A. ―I should always use my beclomethasone inhaler first, then follow it with my albuterol inhaler.‖
101. The nurse is preparing to conduct discharge teaching for a client who had an anaphylactic reaction following administration of ampicillin (Omnipen-N). What instruction is essential for the nurse to provide this client prior to discharge A. Instruct the client to wear a medic-alert bracelet so penicillin will not be given again 102. What is the goal when planning nursing care for a client with edema and leg discoloration secondary to chronic venous insufficiency
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) A. client’s skin integrity will remain intact 103. The nurse is preparing to discharge a client from the hospital who has aphasia secondary to a cerebrovascular accident (CVA). What instruction should the nurse provide the family to assist them in communicating with the client? A. Be consistent in using the same words each time a question is asked. 104. The intensive care department is full and short staffed, so the nursing supervisor informs the charge nurse in the medical department that one nurse must float to the ICU. Which nurse should the medical department charge nurse send to the intensive care department? A. A staff nurse who was cross-trained to work in the critical care department. 105. A mother brings her newborn infant to the well-baby clinic for the one-month check-up. The nurse reviews the infant’s records and identifies that the newborn received the first dose of the HBV immunization upon discharge from the newborn nursery. When should the nurse recommend the administration of the next booster for the HBV series? A. During this visit, one-month of age. 106. When assessing a restless intubated client who is on a mechanical ventilator, the nurse auscultates breath sounds on the right side of the chest only. What action should the nurse implement next? A. Reposition the depth of the endotracheal tube. 107. A male client taking several medications complains of sexual dysfunction. The nurse knows that this is a side effect commonly associated with which of his current medications? A. Enalapril maleate (Vasotec). 108. A client with a cervical spinal cord injury sustained during a motor vehicle crash has been brought to the emergency department. The client has a respiratory rate of 30 and irregular. What action will the nurse take at this time? A. Prepare for immediate intubation. 109. An adolescent male client tells the mental health counselor about sniffing paint thinner with friends on weekends. What should the counselor suggest to the healthcare provider about this client’s care? A. Have testing to evaluate for hearing loss. 110. While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. Action?
A. Measure the length of the apneic periods.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 111. The nurse is preparing to administer the 0700 dose of 20 units of Humulin R to an 8-yr old girl Dx with type 1 diabetes. The mother comments that her daughter is a very picky eater and many times does not eat meals. Intervention? A. Ask the girl if she will be eating her breakfast this morning 112. The nurse is caring for a 10-yr old who is Dx with acute glomerulonephritis. Which outcome is the priority for this child? A. Fluid balance maintained as evidenced by a urine output of 1 to 2 ml/kg/hr 113. A 20-yr old male client is Dx with Ewing’s sarcoma following examination for a knee injury. Which instruction is most important for the nurse to provide the client? A. Seek treatment for the sarcoma immediately 114. The nurse in the newborn nursery admits a baby from L & D who is suspected of having a congenital heart Dz. Which findings help to confirm this diagnosis? A. Centralized cyanosis and tachycardia when crying
115. A client who is bleeding after a vaginal delivery receives a prescription for methylergonovine (Methergine) 0.4mg IM every 2 hours, not to exceed 5 doses. The medication is available in ampoules containing 0.2 mg/ml. What is the max dosage in mg that the nurse should administer to this client? A. 2 116. A male client admitted three days ago with respiratory failure is extubated and with 40% oxygen per face mask is initiated. Currently his temperature is 99, cap refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation? A. Maintains effective breathing pattern 117. A client with a C-6 spinal injury changes to a breathing pattern of shallow respirations and dyspnea twelve hours after the causative incident. The nurse should notify the HCP and implement which intervention? A. Prepare for intubation with an endotracheal tube 118. A client’s right to give informed consent is based on which ethical principle? A. Respect for autonomy
119. When establishing isolation supplies……for a shunt A. Client’s most recent white blood cell 120. A male client is scheduled for a cardiac Catheterization? In the morning, which interventions should the nurse plan for implementing prior to this procedure?
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) A. Explain that a flushed feeling may be experience throughout his body when the dye is injected
121. An adult male client tells the nurse that he believes someone is trying to obtain his computer records, which his wife reports are recreational in nature. The client insists that an elaborate alarm system needs to be installed in his home. The nurse knows that the client is exhibiting which sign or symptom? A. Ideas of reference
122. While preparing a sterilized field prior to doing sterile dressing change, the nurse drops a sterile gauze pan on the edge of the sterile field. What is the best nursing action? A. Use a sterile glove to remove the contaminated gauze 123. A client who is receiving peritoneal dialysis is assigned to a nurse who has not performed this procedure previously. Which actions should the nurse implement before beginning the procedure? A. Seek assistance from a nurse experienced with the procedure 124. A client has a prescription for azithromycin 500mg diluted in 250 ml of normal saline IV q24h for three doses. What action should the nurse implement? A. Set the dose times for q8h 125. A client with a psychotic disorder is receiving haloperidol (Haldol) 3 mg IM q30 minutes x 3 hours for agitation control. The medication is available in 5mg/ml. How many ml will the client receive over the next 3 hours A. 3.6 126. The nurse plans to administer 1 teaspoon of a liquid to a toddler. What is the most accurate way to administer the medication A. measure the medication in an oral syringe 127. When assessing a client who had a supratentorial craniotomy, what action should the nurse implement when determining the client’s Glasgow coma scale (GCS) rating A. instruct the client to raise an arm 128. A client with a prescription for ―do not resuscitate‖ (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement A. the client’s need for pain medication should be determined
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 129. In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement A. document the extent of the bruising in the medical record
130. A client who is admitted to the hospital is suspected of having meningitis. The nurse should plan to prepare the client for which diagnostic test A. lumbar puncture 140. The school nurse is planning to begin an obesity screening program in a school system. It is best to begin the screening program with which group A. kindergarten
141. During a home visit, the nurse determines that a male client is experiencing symptoms that should be controlled by his prescribed medication. The client states that he forgot when he was supposed to take his medications. What is the priority nursing problem when the nurse develops the plan of care for this client A. ineffective health maintenance related to lack of knowledge 145. Immediately after an elective cardioversion for a rapid supraventricular tachycardia (SVT), a male client who was premedicated with hydromorphone (Dilaudid) and midazolam (Versed) is difficult to arouse. His vital signs are: oxygen saturation 94% while receiving oxygen at 2L/minute per nasal cannula, heart rate 78 beats/minute, respirations 6 breaths/minute, and blood pressure 102/70. Which intervention should the nurse implement A. give IV naloxone (Narcan) 146. The parents of two children with sickle cell disease ask the nurse to explain why both of their children have this disease. Which concept should the nurse use to provide an explanation? A. Each child has a 25% chance of inheriting the sickle cell trait from both parents.
147. A client with a cervical spinal cord injury is brought to the emergency center. What should be the nurse’s priority assessment? A. Assess the respiratory pattern. 148. A 13-year-old female client is evaluated at a mental health clinic because her parents suspect she is using an illicit substance. Symptoms reported to healthcare provider include sleep disturbances, slurred speech, mild hand tremors, and trouble hearing. Based on these symptoms, the nurse should screen for which substance? A. Paint thinner.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 149. The charge nurse is developing the nursing guidelines for a coronary care unit. Which reference is likely to be the most useful in developing these guidelines? A. The Scope of Standards of Practice from the American Nurses’ Association.
150. A male client who is in the day room becomes increasingly angry and aggressive when he is denied a day-pass. Which action should the nurse implement? A. Decrease the volume on the television set. 151. The nurse is assessing a client following a thoracotomy and left lung pneumonectomy. What assessment finding should the nurse anticipate? A. Absent breath sounds on the left side of the chest. 152. The nurse is preparing to instruct a client about the rights and responsibilities of being admitted to a cardiac care unit. What will the nurse use as a reference when teaching this client? A. Legislation on Advance Directives. 153. A client receiving treatment in a mental health facility becomes agitated and begins to act inappropriately in the client lounge. Which action would the nurse make at this time? A. Instruct all clients to begin clapping their hands together. 154. During a physical examination the nurse assesses no breath sounds over the client’s left lung fields. Which information in the client’s medical record would explain the absence of breath sounds? A. Pneumonia 6 months ago. 155. When caring for a laboring client whose contractions are occurring every 2 to 3 minutes, the nurse should document that the pump is infusing how many ml/hr? A. 42 156. The nurse in a community health clinic is interviewing a female client who has three children. The client tells the nurse she has a new man in her life, with whom she is having a sexual relationship, and they both smoke cigarettes. Information to provide? A. A diaphragm and condom provide effective contraception when used together 157. An adult male admitted to the psych unit from ED because he is in the manic stage of bipolar disorder. He has lost 10 lbs in the last two weeks and has not bathed in a week because he has been ―trying to start a new business‖ and is ―too busy to eat.‖ He is alert and oriented to time, place, and person, but not situation. Dx? A. Imbalanced nutrition 158. After performing a focused assessment for a male client with Addison’s disease, the practical nurse reports to the charge nurse that the clients’ mucus membranes are moist and he
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) has strong peripheral pulses and his blood pressure is 132/88. The client verbalizes understanding of his illness and importance of taking his medication daily, which action should the nurse implement? A. Document and continue monitoring 159. What instruction should the nurse include in the teaching plan of a client who is beginning to take the prescription drug Atabuse (Disulfiram) A. Read labels of over the counter drugs carefully
160. The nurse identifies physical signs of Trisomy 21- Down syndrome in a 3 month-old infant during a well child visit. Which focused assessments are most important for the nurse to complete? A. Overall Health status Hearing status Vision status
1. A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take? A) allow the client to use a bedpan B) assist the client to the bathroom C) perform a sterile vaginal exam D) explain the fetal head is descending 2. The nurse assesses a 78-year old male client who has left-sided heart failure. Which symptoms would the nurse expect this client to exhibit? A) dyspnea, cough, and fatigue B) hepatomegaly and distended neck veins C) pain over the pericardium and friction rub D) narrowing pulse pressure and distant heart sounds 3. A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for a 22-year old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can’t take her behavior any more since all she does is care for their son. What intervention should the nurse implement? A) schedule a home visit in the afternoon to assess the son and client’s role as caregiver B) acknowledge the client’s stress and suggest that she consider respite care C) provide feedback to the client about her atonement for guilt about her son’s impairement D) teach the client to problem-solve for herself and establish her own priorities 4. The nurse plans to administer a scheduled dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that the client’s telemetry pattern shows a second
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) degree heart block with a ventricular rate of 50. What action should the nurse take? A) administer the Toprol immediately and monitor the client carefully until the heart rate increases B) provide the dose of Toprol as scheduled and assign a UAP to monitor the client’s BP q30 minutes C) give the Toprol as scheduled if the clien’ts systolic blood pressure reading is greater than 180 D) Hold the scheduled dose of Toprol and notify the healthcare provider of the telemetry pattern 5. A client who developed Syndrome of Inappropriate Antidiuretic Hormone (SIADH) associated with small cell carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the healthcare provider? A) insomnia B) muscle cramping C) increased appetite D) anxiety 6. In determining the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition? A) high urinary pH B) abdominal ascites C) orthopnea D) fever 7. The nurse is reviewing a client’s electrocardiogram and determines that the PR interval (PRI) is prolonged. What does this finding indicate? A) initiatin of the impulse from a location outside the SA node B) inability of the SA node to initiate an impulse at the normal rate C) increased conduction time from the SA node to the AV junction D) interference with the conduction through one or both ventricles 8. The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede method. When performing a return demonstration, the client applies pressure to the umbilical area of his abdomen. What instruction should the nurse provide? A) stroke the inner thigh below the perineum to initiate urinary flow B) contract, hold, and then relax the pubococcygeal muscle C) pour warm water over the external sphincter at the distal glans D) apply downward manual pressure at the suprapubic region 9. A 35-year-old female client has just been admitted to the postanesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse’s accurate understanding of the expected outcome for the client following this surgery? A) supplemental hormonal therapy will probably be unnecessary B) the thyroid will regenerate to a normal size within a few years C) the client will be restricted from eating seafood D) the remainder of the thyroid will be removed at a later date 10. A client with gestational diabetes, at 39-weeks gestation, is in the second stage of labor. After delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? A) prepare the client for an emergency cesarean birth B) encourage the client to move to a hands-and-knees position C) assist the client to sharply flex her thighs up against the abdomen D) lower the head of the bed and apply suprapubic pressure
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 11. The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic? A) low bioavailability B) rapid onset of action C) short half life D) narrow therapeutic index 12. Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective? A) decreased abdominal girth B) increased blood pressure C) clear breath sounds D) decreased serum albumin 13. When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do? A) help the client to stand B) report the fall to the nurse-manager C) get a blood pressure cuff D) check for any abrasions or bruises 14. During the initial newborn assessment, the nurse finds that a newborn’s heart rate is irregular. Which intervention should the nurse implement? A) apply oxygen per nasal cannula at 3L/min B) notify the pediatrician immediately C) teach the parents about congenital heart defects D) document the finding in the infant’s record 15. A client is diagnosed with a frontal lobe glioma, which is a benign brain tumor. When teaching the client about the tumor, which information should the nurse consider? A) personality changes or expressive aphasia are likely B) vision and hearing will be affected in the future C) surgery is not indicated unless the tumor becomes malignant D) if the tumor metastasizes, surgical intervention is necessary 16. A client who has suffered 3rd degree burns over 60% of the body is admitted to the emergency department. The healthcare provider writes a prescription for ―IV Lactated Ringer’s 350 ml/hr.‖ Which intervention should the nurse implement? A) call the healthcare provider and question the prescription B) obtain an intravenous infusion pump prior to administering the IV C) administer the Lactated Ringer’s at 350 ml/hr via gravity infusion D) collaborate with the pharmacist to recalculate the infusion rate 17. A male client with HIV, who is being admitted to a healthcare facility, tells the nurse that he is concerned about his right to have access to his records and explanations regarding his treatment and the cost of such treatment. Which resource should guide the nurse’s response to this client? A) the Patient’s Bill of Rights B) the hospital policy and procedure manual C) the Nurse Practice Act D) the client’s Durable Power of Attorney 18. When assessing the oral temperature of an adult client at 6:00 p.m., the nurse notes that the client’s temperature at 6:00 a.m. was 97.2F, and is now 98.8F. What intervention should the nurse implement? A) administer a PRN dose of medication to reduce the fever B) document this intermittent fever in the nurse’s notes C) notify the healthcare provider of the increase in temperature D) document this temperature variation on the graphic sheet 19. It would be of greatest benefit for the client with which problem related to diabetes mellitus to change from the use of insulin syringes to using an insulin pen for medication administration? A) blindness secondary to diabetic retinopathy B) lipodystrophy from continuous use of one
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) injection site C) hyperglycemia due to noncompliance with diet D) diminished dexterity due to finger paresthesias 20. A one-year-old child with neuroblastoma is crying continuously and is curled into a fetal position. What action is most important for the nurse to implement? A) give a prescribed analgesic B) reduce light and noise in the room C) offer the child a favorite toy to clutch D) ask the parent to rock the child 21. A client diagnosed with major depression is being allowed a week-end pass from the psychiatric unit. Which instruction should the nurse provide to the client’s family? A) limit the number of visitors that come to the home B) keep the client busy during the weekend C) involve the client in usual at-home activities D) instruct family to administer all client medications 22. The nurse is evaluating an asthmatic client’s response to an inhaled corticosteroid medication. What assessment finding indicates that the medication has been effective in controlling the asthma symptoms? The client has increased A) peak flow meter rates B) retraction of the chest muscles C) volume of expiratory wheezes D) viscosity of tracheal secretions 23. In reviewing the goals of ―Healthy People,‖ the nurse determines that the community has a significant problem in preventing dental caries among children. To bring about change that addresses this identified community health problem, where is the best place to initiate a prevention program? A) WIC program intake offices B) pediatricians’ offices in clinics C)social security office D) dentists’ offices in the community 24. In planning care for a client with a nursing diagnosis of ―Impaired mobility,‖ the nurse instructs the unlicensed assistive personnel (UAP) to assist the client with ambulation. Because the healthcare provider has prescribed bedrest for the client, what action should the nurse take? A) instruct the UAP to provide sufficient assistance to ensure client safety during ambulation B) update the plan of care to include ambulatory assistance by the nurse rather than the UAP C) revise the prescribed medical treatment plan to include frequent ambulation with assistance D)change the planned interventions to include range of motion exercises rather than ambulation 25. When assigning an unlicensed assistive personnel (UAP) to assist a client with personal care, which client information is most important for the nurse to provide the UAP? A) prescribed activity level B) the client’s weight C) turning schedule D) IV site location 26. 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? A) postpartum psychosis B) postpartum depression C) paranoid personality D) adjustment disorder 27. The nurse is preparing to discharge a client from the hospital who has aphasia secondary to a cerebrovascular accident (CVA). What instruction should the nurse provide the family to assist them in communicating with the client? A) provide on-going stimulation for the client such as a radio turned on in the room B) speak much slower and louder to help the client with
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) comprehension C) give detailed explanations before assisting the client with any care D) be consistent in using the same words each time a question is asked 28. The intensive care department is full and short staffed, so the nursing supervisor informs the charge nurse in the medical department that one nurse must float to the ICU. Which nurse should the medical department charge nurse send to the intensive care department? A) a nurse who has been working the medical floor since graduation one year ago B) a nurse who has recently transferred from the emergency room to the medical floor C) a staff nurse who was sent to work in the intensive care department yesterday D)a staff nurse who was cross-trained to work in the critical care department 29. A mother brings her newborn infant to the well-baby clinic for the one-month check-up. The nurse reviews the infant’s records and identifies that the newborn received the first dose of HBV immunization upon discharge from the newborn nursery. When should the nurse recommend the administration of the next booster for the HBV series? A)during this visit, one-month of age B) at the next clinic visit, or 3-months of age C) at 6 months of age D) the last two doses should be administered at 11-12 years of age 30. When assessing a restless intubated client who is on a mechanical ventilator, the nurse auscultates breath sounds on the right side of the chest only. What action should the nurse implement next? A) provide comfort and sedation for the client B) apply soft wrist restraints per protocol C) reposition the depth of the endotracheal tube D) mark the lip line on the tube with indelible ink 31. A male client taking several medications complains of sexual dysfunction. The nurse knows that this is a side effect commonly associated with which of his current medications? A) theophylline (Theo-dur) B) enalapril maleate (Vasotec) C) aluminum hydroxide (Mylanta) D) ampicillin (Omnipen) 32. The parents of two children with sickle cell disease ask the nurse to explain why both of their children have this disease. Which concept should the nurse use to provide an explanation? A) all of your children will be carriers of the sickle cell train B) the chances of two children in a family not having the sickle cell disease is 50% C) children of parents with the trait will manifest the disease D) each child has a 25% chance of inheriting the sickle cell trait from both parents 33. A client with a cervical spinal cord injury is brought to the emergency center. What should be the nurse’s priority assessment? A) check the blood pressure B) assess the respiratory pattern C) obtain injury and health history D) assess ability to move extremities 34. A 13-year-old female client is evaluated at a mental health clinic because her parents suspect she is using an illicit substance. Symptoms reported to the healthcare provider include sleep disturbances, slurred speech, mild hand tremors, and trouble hearing. Based on these symptoms, the nurse should screen for which substance? A) marijuana B) ecstasy C) crack cocaine D) paint thinner 35. The charge nurse is developing the nursing guidelines for a coronary care unit. Which reference is likely to be the most useful in developing these guidelines? A) the Americans with
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) Disability Act of 1990 B) the American Heart Association’s recommendations on diet and lifestyle C) the Scope of Standards of Practice from the American Nurses’ Association D) the Patient’s Bill of Rights of 1990 36. A male client who is in the day room becomes increasingly angry and aggressive when he is denied a day-pass. Which action should the nurse implement? A) tell him he can have a day pass if he calms down B) put the client’s behavior on extinction C) decrease the volume on the television set D) instruct the client to sit down and be quiet 37. The nurse is assessing a client following a thoracotomy and left lung pneumonectomy. What assessment finding should the nurse anticipate? A) absent breath sounds on the left side of the chest B) decreased breath sounds on the left, clear breath sounds on the right C) diminished breath sounds auscultated bilaterally D) crackles and wheezes auscultated in the right lung fields 38. A male client with Type 1 diabetes mellitus takes a combination of short-acting and intermediate-acting insulin drugs. The client complains of headaches when awakening and his blood glucose average for the past week has been 210 mg/dl. The nurse recognizes the client is experiencing a daily Somogyi, or rebound effect. Which dosing method is likely to relieve these symptoms? A) move the PM intermediate-acting dose to bedtime B) increase the intermediate-acting dose with evening meal C) increase the short-acting dose before lunch time D) delay the morning doses until after breakfast 39. When obtaining a throat culture from a 6-year-old with possible streptococcal infection, which action is most important for the nurse to implement? A) allow the child to hold the tongue depressor and practice saying, ―Ah.‖ B) swab the child’s erythematous oropharyngeal surfaces or tonsillar pustules C) encourage the parent to hold the child during the procedure D) instruct the child to look at the ceiling and open the mouth widely 40. The nurse is caring for a 42-year-old male client who is excreting less sodium than he is consuming. If this condition continues, what complication can the nurse expect this client to exhibit? A) dehydration B) edema C) hyponatremia D) azotemia 41. Which condition would likely cause secondary polycythemia? A) graft versus host disease B) acute blood loss C) high altitude exposure D) hereditary spherocytosis 42. An infant is treated for intussusceptions with hydrostatic reduction. What instructions should the nurse include in the parent’s teaching plan? A) skills needed for care of a stoma B) signs and symptoms of recurrent C) low-fat, high-protein diet D) steps in tube feeding administration 43. The nurse is planning care for a 48-year-old client, diagnosed with schizophrenia at age 25, who has been taking antipsychotic drugs since diagnosis. Long-term use of these drugs is associated with which side effect? A) parkinsonism B) akathisia C) dystonia D) tardive dyskinesia 44. What instruction is most important for the nurse to provide a client with neutropenia? A) avoid sources of potential infection B) take precautions to minimize bleeding C) schedule regular rest periods D) avoid exposure to excessive ultraviolet light
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 45. A client with acute laryngitis reports feeling ―short of breath.‖ The nurse assesses that the client’s respiratory rate has increased from 16/minute to 28/minute. What intervention should the nurse implement? A) assess the client for stridor and increased respiratory effort B) administer an intravenous analgesic per PRN protocol C) provide written means of communication for the client D) determine the client’s recent exposure to irritating substances 46. When caring for a client who had a craniotomy yesterday for removal of a pituitary tumor, which finding indicates to the nurse that further information is needed? A) suture line is slightly reddened and swollen B) Glasgow coma scale (GCS) score is 14 C) urine output for 8 hours is 2,000 ml with a specific gravity of 1.001 D) white blood cells (WBC) are 11000/mm3 and glucose is 138 mg/dl 47. The nurse is working with an interdisciplinary group to write procedures for assessment of clients from a multiracial inner city population. The guidelines include a statement that reads, ―Remember that all Hispanic clients may not wish to give personal medical information to a stranger.‖ Which action should the nurse take? A) revise the guideline to include a checklist that provides a racial profile B) suggest that the client assessment address this ethnicity group C) conclude that this guidelines is written in a culturally sensitive context D) recommend changing the language that stereotypes one ethnic group 48. What nursing action has the highest priority in preventing postoperative bleeding following a submucosal resection for a deviated septum? A) instruct client to expectorate secretions B) provide mouth care hourly C) maintain intact nasal packing D) reinforce pressure dressing PRN 49. A female client chooses to have a prophylactic mastectomy because she has a positive BRCA1 mutation, her mother died of breast cancer at age 30, and her cousin was diagnosed with breast cancer at age 28. Which intervention is most critical for the nurse to include in this client’s immediate postoperative plan of care? A) determine the client’s understanding of the risk for ovarian cancer B) assess the client’s emotional reaction to prophylactic surgery C) ensure adequate pain control using postoperative analgesics D) review information about available reconstruction choices 50. The psychiatric nurse is called to a train derailment that was likely caused by a terrorist bomb. In triaging those in need of immediate care, what is the priority ranking for these cases? (Arrange these cases in order of priority, with the top item requiring the most immediate care and the bottom item requiring the least priority care.) Correct order (note: not all answer shown): 1) A middle-aged man who is wandering around the scene with blood coming from his head asking for his mother 2) A woman sitting on the ground with a blanket wrapped.. 3) A crying child being held by another passenger, who is asking for his mother who cannot be found 4) A mother and father have just arrived on the scene looking.. 51. A client with pneumonia is admitted with severe shortness of breath and arterial blood gases of pH 7.30, PaO2 60 mm Hg, PaCO2 62 mm Hg, HCO3 35 mEq/liter. Which information should the nurse communicate immediately to the healthcare provider? A) occasional premature
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) ventricular contractions B) complaint of a headache C) heart rate of 115 beats/minute D) drowsiness and difficulty in arousing 52. The nurse is teaching a primigravida, who describes herself as a lacto-vegetarian, about nutrition during pregnancy. Which foods should the nurse encourage this client to include in her diet? A) cheese, green salads, and fruit B) chicken, milk, and green vegetables C) eggs, milk, and green salads D) fish, brown rice and fruits 53. The mother of a 5-year-old boy calls the emergency room and reports that a pot of hot soup was pulled off the stove onto her child’s right arm and leg. What should the nurse tell this mother to do first? A) wrap the child in a blanket and bring him to the hospital immediately B) put him on a warm surface until an ambulance can arrive C) place him in a cool bath and remove his clothing D) immobilize him by wrapping him tightly in a clean sheet 54. A nurse is caring for a client with a diagnosis of acute renal failure who complains of shortness of breath, weakness, headache, and swelling of the lower legs and feet. What nursing interventions should be completed immediately? A) percuss abdomen to check for ascites B) administer PRN dose of ibuprofen (Motrin) C) elevate the head of the bed at least 45 degrees D) encourage the client to deep breathe and cough 55. A client with acute low back pain reports pain radiating down the buttock to below the knee. Initial nursing actions should be based on which interpretation of these symptoms? A) this pain is along the path of the sciatic nerve B) the client is describing classic signs of phantom pain C) ischemic pain is occurring due to arterial compression D) the client is experiencing severe muscle strain and spasm 56. The nurse is attempting to teach a male client newly diagnosed with diabetes how to administer insulin. When the nurse attempts to answer the client’s questions he becomes angry and tells the nurse that the entire process is just too much to learn. What action is best for the nurse to take? A) ignore the client’s outbursts, and continue with the instructions B) explain to the client that he cannot go home until he learns to administer the insulin C) acknowledge the client’s feelings, and tell him that he will eventually be able to do self-administration D) encourage the family to learn how to administer the insulin until the client is better able to handle the procedure 57. In evaluating the effectiveness of a client’s nocturnal sleep patterns, what information is best for the nurse to obtain? A) the number of hours the client sleeps each night B) self-evaluation of feeling well-rested upon awakening C) recall of experiencing dreaming during the night D) the number of times the client voids during the night 58. Four clients present to the Labor and Delivery unit at the same time. The nurse should assess the client with which complaint first? A) urinary frequency and burning on urination B) contractions every 10 minutes C) abdominal pain and bright red bleeding D) has not felt the baby for the last 12 hours 59. The nurse is conducting discharge teaching about the antianxiety drug diazepam (Valium). Which instruction has the highest priority for inclusion in the teaching plan? A) notify the
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) healthcare provider if anxiety continues two weeks after beginning treatment B) crush tablets and take with food or water if they are difficult to swallow C) if muscle spasms occur during treatment, notify the healthcare provider immediately D) evaluate the ingredients of all overthe-counter drugs for alcohol content 60. 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? A) reschedule administration of the antibiotic until after he completes his prayers B) instruct the client that the antibiotics must be given on time to be effective C) ask the pharmacist to supply an oral form of the antibiotic for the client D) notify the healthcare provider that the client has refused the scheduled antibiotic 61. After administering a medication through a nasogastric tube connected to suction, what action should the nurse take first? A) clamp the tube B) re-connect the tube to the suction C) document the medication administration D) discard the supplies used 62. Which of these women, all of whom have recently discovered a new breast lump, is at greatest risk for a diagnosis of breast cancer? A) a 51-year-old whose mother had breast cancer and describes the lump as non-tender B) a 22-year-old who has fibrocystic breast disease and describes the lump as painful C) a 45-year-old who is taking estrogen therapy and has had four children before the age of 28 D) a 55-year-old whose weight is normal for her height, and had one child at age 31 63. Which client situation requires the most immediate intervention by the nurse? A) a six centimeter area of reactive hyperemia is observed over the left trochanter of a bedfast client B) a four centimeter area of dehiscence is observed on a client’s abdominal incision one day after surgery C) a stage II pressure ulcer located on a client’s sacrum is draining a moderate amount of purulent drainage D) a stage IV pressure ulcer has a five centimeter area of necrosis surrounded by a pale pink tissue 64. On admission, the healthcare provider prescribes a broad spectrum antibiotic, ticarcillin (Ticar), for a client with a gram-negative infection. Before administering the first dose, it is most important for the nurse to implement which prescription? A) wound and blood specimens for culture and sensitivity B) irrigation and topical antibiotic application to wound area C) complete blood count and serum electrolytes D) monitor for signs of sodium and fluid retention 65. The nurse observes that a client receiving an aminoglycoside for an infection appears dizzy when ambulating. The nurse should consult with the healthcare provider regarding the need for which test? A) peak and trough B) creatinine clearance C) culture and sensitivity D) white blood cell count 66. The nurse is administering a continuous IV infusion of dopamine (Intropin) to a client. Which assessment finding indicates that the therapeutic effect has been achieved? A) increased blood pressure B) conversion to normal sinus rhythm C) clear breath sounds bilaterally D) decrease in central venous pressure
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 67. The wife of a client with terminal cancer gives the nurse a copy of her husband’s living will. What action should the nurse take? A) place a certified copy of the living will in the client’s chart B) notify the healthcare provider of the client’s wishes C) alert the nursing staff of the client’s do not resuscitate status D) facilitate a family meeting with the palliative care team 68. A client with a fractured femur is placed in traction to immobilize the fracture. When transporting this client to another room, how should the nurse handle the traction? A) release the weights during transport and reconnect them upon arrival B) leave the weights in place for the full duration of the transport C) prevent movement of the weights by resting them on top of the bed until arrival D) increase the amount of weights by 50% during the transport 69. The healthcare provider prescribed triazolam (Halcion) 500 mcg for a client with insomnia. The pharmacy supplies Halcion in 0.25 mg tablets. How many tablets should the nurse administer? (Enter numeric value only) Answer: 2 70. A client who is being prepared for discharge following a transurethral resection of the prostate (TURP) tells the nurse that he is concerned about becoming constipated. Which instruction should the nurse provide to this client? A) use oral stool softeners daily B) take a laxative of choice daily C) use a soft-tip mineral oil enema as needed D) use glycerin rectal suppositories as needed 71. A 3-year-old child visits the clinic with both parents for a well-child check-up. The nurse ascultates bronchovesicular breath sounds in the peripheral lung fields and assesses the child’s respiratory rate at 28 breaths/minute. Which interpretation of this finding is accurate? A) an expected finding B) tachypnea C) asthmatic wheeze D) mucus plug in the bronchus 72. The nurse is providing preoperative teaching to a female client scheduled for surgery tomorrow at an ambulating surgery center. Which instruction is most important for the nurse to include? A) advise the client to make arrangements for someone to drive her home B) instruct the client not to bring any valuable jewelry to the surgery center C) explain to the client that an intravenous line will be started before surgery D) teach the client how to describe her pain using a numeric pain scale 73. In performing an initial assessment of an infant with cryptorchidism the nurse should also assess for which finding? A) a heart murmur and poor weight gain B) a reducible or nonreducible bulging in the inguinal area C) difficulty feeding and a history of frequent emesis D) abnormal bowel sounds and closed fontanels 74. An unlicensed assistive personnel (UAP) reports to the nurse that a postoperative client is complaining of abdominal pain and has a respiratory rate of 32 breaths per minute. What action should the nurse implement? A) use a numeric pain scale to determine the client’s pain level B) tell the UAP to retake the client’s vital signs in thirty minutes C) assist the client with the use of an incentive spirometer D) administer a PRN prescription for oxygen per nasal cannula 75. A 4-year-old boy is admitted to the hospital for a urinary tract infection. Which statement made by the mother warrants further exploration by the nurse? A) ―I am so sorry, but he really asks a lot of questions‖ B) ―He is so active. I’m encouraging him to rest some‖ C) “I think it’s
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) best to discuss his problem outside the room” D) ―He really likes to play with the children’s doll house‖ 76. 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? A) place the infant at the mother’s breast B) compare current vital signs with previous vital signs C) initiate an hourly perineal pad count D) review the client’s record for evidence of birth trauma 77. An infant who weighs 22 pounds is receiving an IV solution at 96 ml/kg/24 hours. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.) Answer: 40 Rationale: 1) 22 lbs divided by 2.2lbs/kg= 10kg. 2) 96ml x 10kg= 960ml/24hours= 40ml/hour 78. The nurse determines that an intravenous infusion in a client’s right forearm is a stage 4 infiltration. After removing the intravenous catheter, what action should the nurse take? A) evaluate the color and temperature of the right hand B) auscultate the client’s breath sounds bilaterally C) assess the range of motion of the client’s right arm D) measure the client’s blood pressure in the left arm 79. In assessing a female client with Type 2 diabetes mellitus, the nurse notes that the client has gained five pounds since her last clinic visit six months ago. The client reports that she has been following her diet and that her glucose levels are under control. What indicator best reflects the client’s control of her diabetes? A) a fasting blood glucose level B) a glycosylated hemoglobin level C) client report of symptoms of hyperglycemia D) a 24-hour urinalysis for ketone bodies 80. The nurse tests a client’s visual acuity and determines that the uncorrected vision is 20/100 in the right eye and 20/80 in the left eye. What does this finding indicate? A) difficulty seeing objects at close range B) difficulty visualizing objects at a distance C) difficulty seeing at any distance D) the left eye is the dominant eye 81. Identify the location of the pinnae that the nurse should pull upward and outward while instilling ear drops into an adult’s ear. (Click the chosen location. To change, click on the new location.) Answer in box area (correct area):
82. A client with a permanent pacemaker develops loss of capture resulting in symptomatic sinus bradycardia at a rate of 38/minute. Which intravenous medication should the nurse prepare to administer immediately? A) atropine sulfate (Atropine) B) amiodarone (Cordarone) C) adenosine (Adenocard) D) atenolol (Tenormin)
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 83. A 25-year-old female client reports to the nurse that she has a throbbing headache over her left eye that began early yesterday right after experiencing dark spots in her vision. Movement makes her nauseous, but lying still in a dark room does provide some relief. Over-the-counter pain medications have not helped. This client is describing which type of headache? A) classic migraine B) temporal arteritis C) sinus headache D) cluster headache 84. A client is admitted to the emergency room because of an overdose of acetaminophen (Tylenol). Following gastric lavage, the nurse should expect to administer which medication? A) acetylcysteine (Mucomyst) B) nifedipine (Procardia) C) haloperidol (Haldol) D) diazepam (Valium) 85. A client with hyperparathyroidism reports increasing lethargy and seems confused. It is most important for the nurse to obtain which serum lab test results? A) potassium B) calcium C) white blood cell count D) hemoglobin and hematocrit 86. The charge nurse is assessing the morning lab work on four clients. Which client’s laboratory findings should prompt the charge nurse to contact the healthcare provider immediately? A) a 50-year-old diagnosed with myocardial infarction who has an elevated CPK-MB on serial cardiac enzymes B) a 35-year-old diagnosed with pneumonia having a white blood cell (WBC) of 13,000 mm3 C) a 29-year-old diagnosed with ulcerative colitis having a serum potassium level of 3.1 mEq/L D) a 74-year-old diagnosed with COPD who has ABGs of pH 7.35, PaCO2 49, PaO2 74, HCO3 26 87. The nurse is assessing an adult who displays stagnation, boredom, and interpersonal impoverishment. Based on Erikson’s developmental model, which stage should the nurse develop interventions for this client? A) generativity versus stagnation B) identity versus role confusion C) intimacy versus isolation D) integrity versus despair 88. The nurse obtains lying and standing blood pressure measurements for a female client who complains of dizziness every time she stands up from the computer at work. The nurse determines that her systolic pressure decreases 24 mmHg when she stands. What intervention is most important for the nurse to implement? A) recommend that the client drink plenty of water every day B) determine if the client takes antihypertensive medications C) encourage the client to flex her feet before rising slowly D) review the client’s history for any incidence of syncope 89. A client is receiving lidocaine IV at 3mg/minute. The pharmacy dispenses a 500 ml IV solution of normal saline (NS) with 2 grams of lidocaine. The nurse should regulate the infusion pump to deliver how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number.) Answer: 45 Rationale: 1) The available solution of 2 grams (2000mg) in 500ml is 4 mg/ml. 2) Use the formula, prescribed dose (mg/minute) x 60 minutes/hour divided by available solution concentration (mg/ml). 3 mg/minute x 60 minutes/hour divided by 4mg/hour = 45ml/hour. 90. A school-age child with asthma is intubated and placed on a mechanical ventilator. The parents of the child are pale, holding onto each other, and have tears in their eyes. What statement by the nurse is most therapeutic when first interacting with these parents? A) ―The
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) ventilator is making sure your child is getting enough oxygen‖ B) ―Your child is resting comfortably at the present time‖ C) “It must be difficult for you to see your child go through this” D) ― Your child is in good hands. Everything is going to be okay‖ 91. The nurse is conducting a community education program on osteoporosis prevention. Which physical activity would be best to recommend to women 65 years of age and older for prevention of osteoporosis? A) brisk walking for 2 hours over a period of a week B) aerobic dancing one hour a day, five days per week C) swimming 45 minutes a day, three times per week D) stretching exercises for 20 minutes three times per week 92. A client is admitted to the nursing unit with a possible bowel obstruction. The nurse auscultates high-pitched bowel sounds in the upper quadrants of the client’s abdomen. What is the significance of this finding? A) indicates beginning resolution of the obstruction B) documents accurate placement of the nasogastric tube C) reflects the probability of impending peritonitis D) provides data about the location of the obstruction 93. Which statement by a client would cause the nurse to suspect that the client may be experiencing a myocardial infarction? A) ―My chest hurts when I walked up the stairs‖ B) “It seems like vise is squeezing my chest” C) ―I have a burning pain in my chest when I lie down‖ D) ―I have chest pain when I take a deep breath‖ 94. The nurse is administering an intramuscular injection and performs the Z-track technique. At what point should the nurse release the tissue that is retracted laterally during the injection? A) after the insertion of the needle into the muscle mass B) after performing aspiration to detect vessel entry C) after injection of the medication into the muscle mass D) after the needle is withdrawn from the skin surface 95. The nurse is caring for a 5-year-old child with Reye’s syndrome. What goal has the highest priority in caring for this child? A) reduce cerebral edema and lower intracranial pressure B) promote oral fluid intake and prevent kidney damage C) prevent long-term complications and cardiac damage D) control hypertension and septic shock 96. An adult male who admits to abusing IV drugs obtains the results of HIV testing. When informed that the results are positive, he states that he does not want his wife to know. What action should the nurse take? A) inform the wife of her health risk related to her husband’s HIV results B) counsel the client about the importance of notifying his sexual partner C) tell the client he is required by law to inform his sexual partners of his HIV status D) report the client’s results as a sexually transmitted case to the health department 97. When bathing an elderly client, the nurse notes that the client’s skin is very dry, flaky, and rough. Which nursing interventions should be added to this client’s plan of care? A) provide alcohol-based lotions to prevent cracking B) decrease bath to every other day using nonirritating soap C) use antimicrobial soaps to reduce infection risk D) apply protective ointment containing zinc oxide to posterior side 98. A male client was admitted to the intensive care unit three days ago following a motor vehicle collision and is today being discharged to the medical unit. One hour before discharge,
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) his blood pressure is 160/110 and pulse is 120 beats/minute. He tells the nurse, ―I feel like my skin is crawling.‖ Which lab value is most important for the nurse to assess? A) admission alcohol level B) hemoglobin and hematocrit C) serum amylase D) white blood count (WBC) 99. A male client with diabetes and hypertension has begun to exhibit signs of diabetic retinopathy. To help decrease the retinopathy, the nurse should encourage the client to try and become more diligent in managing which situation? A) avoiding large crowds to reduce infections B) maintaining better control of blood sugar levels C) taking anti-hypertensive drugs as directed D) seeing an ophthalmologist every 6 months 100. The wife of a terminally ill client is concerned because her husband insists on talking about past events. Which response is best for the nurse to provide? A) notify the hospital chaplain of the wife’s concern B) encourage the wife to provide current information to her husband C) support the wife by listening attentively to her complaints D) explain that reminiscing about one’s life is common among the dying 101. The nurse is caring for a toddler who has a medical diagnosis of coarctation of the aorta. Which assessment finding should the nurse report to the healthcare provider immediately? A) blood pressure higher in upper extremeties B) weak femoral pulses C) crackles at the end of inspiration D) pulse oximeter reading of 94% 102. A client’s case is being reviewed by the hospital’s multi-disciplinary ethics committee. What information could the nurse provide to the committee regarding this case? A) descriptions of client behavior during the hospitalization that indicate ineffective coping B) information about treatment alternatives that offer the greatest chance of recovery C) counsel on how to legally document the client’s wishes to have the living will extracted D) advice about handling a spiritual conflict a client may experience as a result of an ethical crisis 103. A 16-year-old female client who attempted suicide that morning is admitted to the psychiatric unit. To determine the seriousness of the adolescent’s suicide attempt, which question is most important for the nurse to ask the family? A) ―Has she ever attempted suicide before?‖ B) ―How long has she seemed depressed?‖ C) “How did she attempt to kill herself?” D) ―Has anything occurred which might have precipitated this suicide attempt?‖ 104. A high school football player comes to the clinic complaining of severe acne. The mother reports recent behavior changes, including irritability and suspiciousness of friends. The nurse’s assessment reveals an elevated blood pressure. Which intervention should the nurse implement first? A) encourage the client to see a dermatologist B) inquire about possible use of anabolic steroids C) refer the adolescent to a substance abuse program D) suggest a low-salt, low-fat, caffeine-free diet 105. In caring for a client with a fracture of the femure, the nurse should be alert for compartment syndrome. Which symptom is characteristic of this complication? A) tachycardia and petechiae over the chest wall and buccal membranes B) deep, throbbing, unrelenting pain which is not controlled with opiods C) acute anxiety, diaphoresis, and elevated blood pressure D) positive Homan’s sign with calf tenderness and warmth
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 106. A child is admitted to the hospital with diarrhea and vomiting. Potassium chloride is prescribed for inclusion with rehydration IV fluids. Prior to administering the potassium, the nurse should ensure that which condition exists? A) the client has had no cardiac arrhythmias in the last 24 hours B) the oxygen saturation level per pulse oximeter is greater than 95% C) the client is able to void, assuring kidney function is present D) the client has stopped vomiting before the potassium is added to the IV fluids 107. A client whose blood type is A, Rh negative is scheduled to receive a unit of blood. Two nurses verify the blood type and proceed with the transfusion. One of these nurses should stop the administration of the blood based on which data? A) the blood bag label, tag, and requisition slip state Rh negative B) the nurse identifies the client by checking the room number C) one nurse stays for 15 min. after the initiation of the transfusion D) the collection of vital signs every hour is delegated to an UAP 108. The nurse has not finished administering routine oral medication because one client experienced chest pain and another rectal bleeding. It is now dinner time and two clients must be fed. The unlicensed assistive personnel (UAP) is filling water pitchers, and the practical nurse (PN) is charting vital signs. Which change in assignments is best for the team leader to make? A) UAP monitor client with rectal bleeding, PN feed the two clients, and RN finish oral medications and monitor the client with chest pain B) UAP feed the two clients, PN finish oral medications, and RN monitor clients with chest pain and rectal bleeding C) UAP feed the two clients, PN monitor clients with chest pain and rectal bleeding, RN finish oral medications D) UAP record vital signs, PN feed two clients, RN finish oral medications and monitor clients with chest pain and rectal bleeding 109. A postoperative client has developed an evisceration. Which nursing diagnosis should be added to the client’s plan of care? A) bowel incontinence B) fluid volume deficit C) impaired skin integrity D) altered breathing patterns 110. The nurse is caring for a male client who suffered a right cerebrovascular accident (CVA), resulting in left-sided hemiparesis. Which observation of the client indicates that he is experiencing homonymous hemianopia? A) neglecting the left side of his body B) complains of ringing in the ears C) eyes are reddened and inflamed D) states the bright lights bother him 111. While completing the admission assessment of a client at 24-weeks gestation who is contracting every 5 minutes, the nurse notes several bruises on her abdomen. The client reports that the bruises are the result of her boyfriend kicking her in the stomach. In what order should the nurse implement these nursing actions? (Arrange the options in the order they should be performed with the first action on top and the last action on the bottom.) Answer of correct order: 1) document the fetal heart rate 2) administer the prescribed tocolytic 3) take pictures of the abdominal bruising 4) notifiy the police of the assault 112. Following a transient ischemic attack (TIA) during which a male client experienced hemiparesis, he asks the nurse if he had a ―stroke.‖ What is the best response by the nurse? A) “This attack is not a stroke, but indicates you are at risk for a stroke” B) ―You experienced a stroke caused by lack of oxygen to your brain‖ C) ―This type of attack is very different from,
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) and not related to, a stroke‖ D) ―This type of stroke is usually temporary and has few residual effects‖ 113. A male client returns to the acute care unit following surgery with sequential compression devices in place. The nurse observes that the client dorsiflexes his feet frequently. What action should the nurse implement? A) encourage the client to perform foot exercises regularly while his mobility is limited B) offer to massage the client’s feet and legs while assisting him with personal care C) remove the sequential compression devices while the client exercises his feet D) advise the client to avoid flexing his feet while wearing the compress devices 114. A healthcare provider prescribes butorphanol (Stadol) 1 mg and promethazine (Phenergan) 12.5 mg IM for a 38-week primigravida who is in early labor. Stadol is available in 2mg/1 ml vials and Phenergan is available 50 mg/1 ml ampoules. The nurse plans to administer both drugs in one injection. How many ml should the injection contain? (Enter numeric value only. If rounding is required, round to the nearest hundredth.) Answer: 0.75 Rationale: 1) Stadol: 2mg/1 ml = 1 mg/ x ml = 1 divided by 2 = 0.5 2) Phenergan: 50 mg/1 ml = 12.5 mg/ x ml= 12.5 divided by 50 = 0.25 3) 0.5 + 0.25 = 0.75 115. A client who is immunosuppressed because of treatment for systemic lupus erythematosus (SLE) delivers a viable infant at 37-weeks gestation by cesarean section. Four days later she has a fever of 102.6F and diarrhea. A stool specimen is positive for Clostridium difficile. What action should the nurse take? A) place the client in enteric isolation B) remove the infant from the mother’s room C) put the mother and infant in separate isolation rooms D) do not allow visitors until the diarrhea has stopped 116. Which statement by a client indicates to the nurse that the client understands how a newly prescribed transdermal medication will be administered? A) ―The needle is injected just barely under the skin‖ B) ―The medicine is injected in the tissue just below the skin layer‖ C) “The medicine will be applied directly on my skin” D) ―I will place the medicine directly under my tongue‖ 117. Prior to administering digoxin (Lanoxin), two nurses assess the heart rate of a client with atrial fibrillation. They both obtain an apical pulse rate of 96 beats/minute and a radial pulse of 77 beats/minute. Calculate the client’s pulse deficit. (Enter numeric value only.) Answer: 19 Rationale: To calculate pulse deficit, radial pulse is subtracted from the apical pulse. 96-77 = 19. 118. A client diagnosed with a deep vein thrombus (DVT), followed by a diagnosis of pulmonary embolism (PE), is receiving heparin via an infusion pump at a rate of 1400 U/hr. The client tells the nurse, ―I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home.‖ What response is best for the nurse to provide? A) ―Why are you so anxious to leave the hospital when you know you are not well enough yet?‖ B) ―You seem to be concerned about the length of time it takes for Heparin to dissolve this clot‖ C) “Heparin prevents future clot formation, but your risk of bleeding needs to be monitored closely” D) ―Let me contact your surgeon and find out if Heparin IV therapy can be given to you at home‖
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 119. A male translator is working with the nurse who is giving discharge instructions to a nonEnglish speaking client. When the translator restates what the nurse is saying, it appears that he is saying much more than what the nurse said. What action should the nurse take? A) say nothing to the translator since he is licensed to explain the instructions B) ask the translator if there is a reason for the lengthiness of the translation C) request another translator to verify the accuracy of the translations D) remind the translator that his role is to only restate what the nurse says 120. A nurse is named as a defendant in a malpractice case. What action should the nurse take? A) purchase additional professional liability insurance B) talk to the client (plaintiff) and apologize for the harm suffered C) contact the nurse’s personal professional liability insurance company D) discuss the client’s claim with other nurses to gain their support as witnesses 121. A female client admitted to a long-term care facility appears confused and frightened. She offers her belongings, including valuable jewelry, to members of the nursing staff if they promise to stay with her and not leave her alone. What action should the nurse implement? A) accept the client’s jewelry as a gift and assign a staff member to remain with the client B) remove the client’s valuables and place them in the client’s drawer out of sight of visitors C) encourage the staff to pretend to accept the gifts until the client feels secure at the facility D) make an inventory of the belongings and send the valuables home with a family member 122. The nurse is teaching a childbirth education class to prospective parents and describing possible signs of labor. Class participants should be taught that which sign should be reported to the healthcare provider immediately? A) contractions occurring 10 to 15 minutes apart B) leaking of fluid from the vagina C) passing of excessive mucous from the vagina D) lower back pain and urinary frequency 123. The nurse performs a series of heel sticks to obtain glucose levels on a large-for-gestational age (LGA) newborn. Because the glucose was 48 mg/dl on admission and 39 mg/dl one hour later, a venous specimen for laboratory analysis of serum glucose concentration is obtained. What action is most important for the nurse to implement? A) provide an external heat source to prevent shivering B) take the newborn to the mother to breastfeed C) notify the pediatric healthcare provider D) place a cap on the infant to prevent heat loss 124. A home health care agency set the goal: ―Use informatics as a method for improving health care delivery.‖ What nursing action is directed toward achieving this goal? A) enter accurate client data into client’s computerized medical records B) encourage clients and families to help develop the client’s plan of care C) use a standardized worksheet to organize assigned daily client care D) document client care using an interdisciplinary problem-oriented record 125. A female client with Type 1 diabetes mellitus is trying to lose weight, and recently started an exercise program. Which information is most important for the nurse to provide this client? A) increase carbohydrate intake before exercising B) take insulin before exercising C) drink water while exercising D) wear shoes that are well-fitted and white socks
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 126. During the second treatment with an IV antibiotic, the client develops a rash on the upper torso. What intervention should the nurse implement first? A) document the finding in the client’s record B) observe the client’s breathing pattern C) take the client’s blood pressure D) notify the healthcare provider 127. A male client with moderate Alzheimer’s disease had abdominal surgery yesterday. Today, when the nurse begins to perform a dressing change, the client states, ―I don’t want you to change my dressing.‖ What is the best initial action for the nurse to take? A) do not change the dressing and note ―refused‖ in the client’s medical record B) explain the importance of the dressing change and proceed with the procedure C) leave the room and re-approach the client in about 30 minutes D) ask another nurse who has cried for the client before to do the dressing change 128. The nurse is preparing a teaching plan for a 23-year-old female client who has had a kidney transplant. What should be the nurse’s focus in conducting this teaching? A) explaining that the immunosuppressant medications must be decreased gradually when being discontinued B) describing the necessity of eating high purine foods and avoiding foods high in calcium and oxalate C) stressing the importance of life-long medical follow-up care after the kidney transplant D) outlining the signs of rejection, which include increase in urinary output and weight loss 129. What instruction should the nurse include in the discharge teaching plan of a client with ulcerative colitis who has had a traditional ileostomy? A) demonstrate and provide written instructions on how to irrigate the ostomy B) explain that a high-fiber diet should be followed for the first 6 to 8 weeks after ileostomy C) instruct the client to empty the ostomy appliance once a day D) tell the client to notify the healthcare provider if the stoma becomes purple 130. The community health nurse is planning a nutritional program that targets older adults who live alone and who may be in need of additional community services. Which intervention should the nurse implement first? A) gather information about the makeup of the population using a windshield survey B) prepare visual aids, handouts, and food samples for program participants C) post announcements at the community center about upcoming topics D) develop an evaluation plan that focuses on the effectiveness of the program 131. A family member contacts the nurse at the community mental health center and wishes to share concerns and ask questions about a client’s medications. What action is best for the nurse to take? A) obtain written consent from the client to talk to the family member about treatment B) determine if the client knows that the family member is requesting this information C) make a note in the chart about what was disclosed during the interaction D) ask the family to explain how the nursing staff can be most helpful 132. A family member brings a basket of fresh fruit to a client who has a decreased neutrophil count as a result of chemotherapy. What action should the nurse take regarding this gift? A) encourage the client to eat the fruit as a small, healthy snack B) encourage the client to eat the fruits that are high in vitamin C C) remove any of the fruit that provides high fiber D) remove all of the fruit from the client’s room
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 133. A male client who has a serum potassium level of 5.9 mEq tells the nurse that he has decided to leave the hospital, even though his healthcare provider has not discharged him. He states that he does not care if he is discharged, he is refusing all treatments. It is most important for the nurse to ensure that the client understands which fact prior to leaving the facility? A) he must sign the hospital’s Against Medical Advice (AMA) form, which will make him responsible for any consequences of not receiving medical care B) he must be informed that insurance will not pay for his hospital stay if he leaves against medical advice C) he must understand that his condition is extremely serious and that he could die as a result of this decision D) he should know that he can return to the hospital at any time for treatment if he changes his mind 134. 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? A) rinse the eye and gently remove the object B) remove the object and patch the eye C) call the parent and send the child home D) have the parent take the child for emergency help 135. What is the rationale for the nurse to teach a client to compress the lacrimal duct after eye drop instillation? A) to prevent systemic absorption of the medication B) to reduce pain and discomfort C) to prevent irritation of the lacrimal gland D) to reduce eye ―tearing‖ 136. Three days after surgery, a male client who had a laryngectomy has an elevated pulse and respiratory rates. His skin is dry to touch and he is beginning to thrash about in the bed. What intervention should the nurse implement first? A) call the healthcare provider B) suction the client’s tracheostomy C) apply restraints to the client’s hands to prevent injury D) administer a sedative prescribed PRN for restlessness 137. A client with chronic kidney disease (CKD) is scheduled for hemodialysis Monday and Wednesday mornings. Based on findings reported in the client’s medical record, which action should the nurse implement on Wednesday morning? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.) A) withhold the morning dose of lisinopril (Zestril) B) keep the client NPO for hemodialysis C) notify the healthcare provider of the laboratory results D) give a prn dose of aspart (Novolog) insulin 138. A client just returned to the nursing unit after surgery, and initial assessment findings include a pulse rate of 120 beats/minute, restlessness, cyanosis, and gurgling sounds on inspiration and expiration. What action should the nurse take first? A) perform oropharyngeal suctioning B) report the findings to the healthcare provider C) administer oxygen via a rebreathing mask D) bring intubation supplies to the room 139. In shift report the charge nurse is told of several problems. Which problem should the nurse address first? A) a bucket of water was spilled in the hallway B) a client’s wife has asked to speak with the charge nurse C) the census report has not been completed D) one staff member has not reported to work 140. The nurse plans to administer an IV heparin bolus of 80 units/kg to a client who weighs 210 pounds. How many units should the nurse administer? (Enter numeric value only. If rounding is
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) required, round to the nearest whole number.) Answer: 7636 Rationale: 1) Calculate the client’s weight, 210 pounds/2.2kg=95.45kg 2)Calculate the client’s dose, 80 unitsx95.45kg=7636 units 141. The nurse administers NPH insulin to a child at 7:30 a.m. When should the insulin be most effective in lowering the blood sugar? A) before lunchtime B) mid-afternoon to dinner time C) late evening to bedtime D) during the night 142. The nurse is beginning the process of changing the central venous catheter dressing of a client receiving total parenteral nutrition. After applying sterile gloves, what action should the nurse take? A) cleanse the site B) remove the original dressing C) secure the transparent dressing D) apply a face mask 143. A nurse-manager is preparing an annual budget for the unit. Nursing salaries should be included in which component of the budget? A) capital budget B) budget variance C) operating budget D) cost containment 144. A middle-aged female client is admitted to the hospital with a medical diagnosis of acute renal failure (ARF). The healthcare provider informs her that her treatment program will include hemodialysis. Which response demonstrates that this client understands what will occur with hemodialysis? A) ―Our children were coming for a visit over Christmas. Now we will have to cancel our holiday plans‖ B) ―I don’t understand how this could have happened to me. No one in my family has ever ahd to be on dialysis before‖ C) ―Dialysis will not interfere with my job at all. I am off on weekends, so I will just do the dialysis then‖ D) “Using the kidney machine every few days will help rest my kidneys so they can function again” 145. The nurse is assigning rooms for four clients, each newly diagnosed and being admitted to the acute neuro unit for treatment. The client with which diagnosis should be assigned the only private room available? A) brain abscess B) bacterial meningitis C) viral encephalitis D) septic shock 146. While assessing a client with wrist restraints, the nurse first slides two fingers under the restraint, and then notes that the ties are secured to the siderails using a quick-release tie. What action should the nurse implement? A) reposition the restraint ties, securing them to the bed frame B) reapply the restraint, allowing less room under the restraint C) tie the restraints to the siderail using a more secure knot D) document that the client’s restraints are correctly secured 147. Which symptom in a client with fractured ribs indicates the presence of an abnormally warranting immediate intervention by the nurse? A) asymmetrical chest wall excursion B) shallow respirations and refusing to take deep breaths C) complaints of chest pain with movement D) ecchymosis around fracture site 148. A female client presents to the emergency department in the early evening complaining of abdominal cramping, watery diarrhea, and vomiting. She tells the nurse that she was at a picnic and ate barbeque that afternoon. What question is most important for the triage nurse to ask this client? A) ―How high was your temperature when you returned home?‖ B) ―Have you taken any
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) medication to treat this problem?‖ C) “Is anyone else sick who was also at the picnic?” D) ―Have you recently traveled outside the United States?‖ 149. While drawing a blood sample from a 2-month-old diagnosed with Tetrology of Fallot (TOF), the nurse recognizes the onset of a hypercyanotic spell or ―tet spell.‖ After poisoning the infant in a knee-chest position, what should the nurse administer? A) nothing until the episode is resolved B) morphine C) a systemic vasoconstrictor D) oxygen 150. A male client diagnosed with gastroesophageal reflux (GERD) often wakes up at night experiencing heartburn. He tells the nurse that he sleeps with the head of the bed on blocks, and always drinks a glass of milk at bedtime to help him fall asleep. How should the nurse respond? A) “Drinking milk before bedtime can increase your symptoms at night” B) ―A warm drink, such as hot tea or cocoa should be substituted for the milk‖ C) ―Taking an antispasmodic medication with the milk will reduce the symptoms‖ D) ―Milk does contain tryptophan, which helps many people fall asleep‖ 151. A client with myelogenous leukemia is receiving an autologous bone marrow transplantation (BMT). What is the priority intervention that the nurse should implement when the bone marrow is repopulating? A) give sargramostime (Prokine) lyophilized injection B) infuse PRBC and platelet transfusions C) give parental prophylactic antibiotics D) maintain a protective isolation environment 152. A woman is transferred to the intensive care unit after hemorrhaging during childbirth, and a pulmonary artery catheter is inserted. Her PCWP is 3, PAP is 10/2, RAP is -4, and her blood pressure is 80/60. What is the highest priority intervention? A) decrease afterload with fluid restriction B) decrease preload with diuretics C) increase afterload with vasodilators D) increase preload with volume replacement 153. A 78-year-old client in a wheelchair wants to return to bed after eating breakfast. What assessment is most important for the nurse to consider before assisting this client? A) blood pressure of 86/54 B) 30% of diet eaten C) oriented to person only D) inelastic skin turgor 154. A client who began a series of tests for infertility last month cries when telling the nurse, ―I feel like such a failure. I don’t know if I can go through with all these tests.‖ Which response is best for the nurse to make at this time? A) ―Test results come back quickly. We’ll call you as soon as we get them‖ B) “Go ahead and cry. I’m sure this must be very difficult for you” C) ―You’re not a failure! Besides, infertility treatment today is highly successful‖ D) ―Let me call your healthcare provider to explain the infertility treatments you are having‖ 155. A child with diarrhea and dehydration is receiving an IV solution of half-strength saline at 100 ml/hour and is eating ice chips continuously throughout the day. Which laboratory finding is most important for the nurse to monitor? A) sodium B) hematocrit C) creatinine D) urine specific gravity 156. An elderly male client is experiencing urinary incontinence. What is the best initial nursing action? A) restrict the client’s oral fluid intake B) instruct the client to perform intermittent selfcatheterization C) insert an indwelling urinary catheter D) apply an external condom catheter
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 157. A male client develops oral candidiasis. He has MRSA-positive sputum, is dyspneic, and is receiving oxygen per face mask and linezolid (Zyvox) 600 mg BID IV. In planning care for this client, the nurse identifies which factor as the probable cause of the stomatitis? A) sputum infection B) antibiotic therapy C) oxygen administration D) frequent mouth breathing 158. A 38-year-old male client collapsed at his outside construction job in Texas in July. His admitting vital signs to ICU are: BP 82/70, heart rate 140 beats/minute, urine output 10ml/hr, skin cool to the touch. Pulmonary artery (PA) pressures are: PAWP 1, PAP 8/2, RAP -1, SVR 1600. What nursing action has the highest priority? A) apply a hypothermia unit to stabilize core temperature B) increase the client’s IV fluid rate to 200 ml/hr C) call the hospital chaplain to counsel the family D) draw blood cultures x 3 to detect infection 159. The industrial health nurse who works in a mobile clinic is developing an exposure control plan for blood-borne pathogens. Which topics should be included in this plan? (Select all that apply.) A) self-sheathing or needleless medication systems B) negative pressure environments C) masks for respiratory chemicals and toxins D) hepatitis B vaccination series E) punctureresistant containers for needle disposal 160. A male client awaiting surgery tells the nurse that he has some concerns about the surgical procedure that were never addressed. Which nursing intervention best reflects the nurse’s role as a client advocate? A) document the concerns expressed by the client B) encourage the client to verbalize his concerns C) notify the surgeon of the client’s concerns D) review the informed consent form for completeness
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
An infant is unresponsive and gasping for breath. Prior to starting CPR, which site should the nurse palpate for a pulse
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
2016Version/Exam1 spring
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Tarleton State University
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Transition Prof Nurs Practice NUR 460
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
2016 Hesi Version 1
1. Pregnancy Induced Hypertension: high blood pressure, blurred vision, headache, Proteinuria, Abdominal pain 2. A client is comatose upon arrival to the emergency room department after falling from the roof. The client flexes with painful stimuli, and the nurse determines the client’s Glasgow Coma Scale (GCS) is 6. Which intervention should the nurse prepare to implement to maintain the client’s airway. A nasopharyngeal tube. 3.A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention should the nurse implement first? Answer: Assess the client for pallor 4.A client experiencing intracranial hypertension from a traumatic brain injury is admitted to the trauma unit. How should the nurse position the client? Elevated head of bed. 5. Risk management: pt fell while using some equipment… charge nurse trying to find out what
happened- how? - hospital polices 6. The nurse is assessing a 48-year-old client with Guillain-Barre syndrome. What symptom is
this client most likely to exhibit? Decreased mobility of the legs. 7. Preop pt should be npo and pt had a glass of h2o-what to do- Alert surgeon/physician. 8. The nurse is caring for a client diagnosed with myasthenia gravis. Which nursing action is best
to promote independence in this client? Teach the client and family energy conservation techniques. 9. The nurse is assessing a 2-week-old breastfeeding infant. To obtain information about the
adequate nutrition, which question should the nurse ask the breastfeeding mother? ―How many diapers does the infant wet daily?‖ 10. Zyvox & suprainfection – stomatitis 11. Potassium Chloride- Client able to void, assuring kidney function is present.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 12. The nurse has identified four nursing problems for a 13-year-old admitted for depression and
anxiety. What is the priority problem? Risk for self directed violence related to history of self multilation. 13. (Audio/visual)- ask to hear heart sounds- murmur (know difference between S1/S2 sounds 14. The nurse is teaching a client newly diagnosed with diabetes mellitus the signs of
hypoglycemia. What symptom should be included in the description of early signs of hypoglycemia? Tremors. 15. When you are giving asthma med… which one would you give 1
st : 1. bronchodilator 2. Steroid 16. A male client diagnosed with hypertension has a nursing goal of, ―the client will be able to
verbalize ways to decrease blood pressure.‖ What statement by the client indicates that this outcome has been met? ―if I loose weight, quit smoking, and exercise regularly I may not have to take any medication. 17. (Select all that apply) Determining pain level for 3mo old infant- infant will clinch fists,
increase pulse, restlessness, increased respiratory effort 18 Penicillin G procaine (Wycillin) 135,000 units IM is prescribed for an infant with a middle ear infection. The drug is available in a vial of 1,200,000 units /2ml. How many ml should the nurse administer? 0.23. 1,200,000 : 2 ml :: 135, 000 : X 270/1200X = 0.225 ml = 0.23ml 19. Depressed client and best activity- assist client with making cut out cookies 20.The nurse is teaching a client’s caregiver how to cleanse around a wound drain. What is the besy way to explain the proper cleansing technique? Start at the drain site, to avoid bringing skin bacteria toward the wound. 21. CPR priority Arrange in other -1. Establish unresponsiveness. 2. Call for help. 3. Assess patent airway. 4. Assess pt carotid pulses. 155. A client with endometrial carcinoma is receiving
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) brachytherapy and has radioactive Cesium (Cs) loaded in a vaginal applicator. What action should the nurse implement? Wear a dosimeter film badge when in the client’s room 22. Math question with heparin you are given the ml/hr and the units you have to figure out how much the patient is receiving which the answer is 2500 23.Alupent administration- The usual single dose is two to three inhalations. With repetitive dosing, inhalation should usually not be repeated more often than about every three to four hours. Total dosage per day should not exceed 12 inhalations. Alupent (metaproterenol sulfate USP) Inhalation aerosol is not recommended for children under 12 years of age. 24. In scheduling home visits, which client is best for the home health charge nurse to begin to assign to the licensed practical nurse? A bedfast client who needs daily irrigation of a stage 4 pressure ulcer. 25. A 65-year-old female client arrives in the emergency department with shortness of breath and chest pain. The nurse accidentally administers 10 mg of morphine sulfate instead of 4 mg as prescribed by the healthcare provider. Later, the client's respiratory rate is 10 breaths/minute, oxygen saturation is 98%, and she states that her pain has subsided. What is the legal status of the nurse? Answer: The client would not be able to prove malpractice in court. 26. In completing the treatment plan for an 11-year-old who has bipolar disorder, the nurse plans outcomes for the nursing diagnosis, ―Risk for violence towards peers related to impulsivity.‖Which outcome is important? Seeks out staff when having thoughts of harming others. The most important outcome is for the client to seek staff when thoughts of harming others occur.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 27. The nurse is teaching a childbirth education class t prospective parents and describing possible signs of labor. Class participants should be taught that which sign should be reported to the healthcare provider immediately? Answer Leaking of fluid from the vagina 28.The nurse is performing a surgical hand scrub prior to entering the operating room. In what order should the nurse perform the steps of this procedure? (Arrange from first on top on the last bottom). Scrape under the nails with a nail pick. Rinse from the fingertips to the elbow. Use a soapy brush to scrub the hands. Cleanse the arm with a lathered brush 29. How to do surgical scrubbing ( arrange in order)= clean nails, then hands, than arm, than u rinse the whole thing off starting from fingertips to upper arm 30. An elderly client is admitted with a diagnosis of pneumonia. What sign or symptom would require immediate intervention by the nurse? Has become agitated, aggressive and cinfused. 31. A client with gestational diabetes at 39-weeks gestation is in the second stage of labor. After delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? Answer Assist the client to sharply flex her thighs up against the abdomen 32.While assessing a client’s blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. What action should the nurse implement next? Answer: Release the air and reinflate the cuff to 30 mm Hg above the client’s previous systolic reading. 33. A 6-month-old male with bronchiolitis is admitted to the hospital. I monitoring the respiratory
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) status of the child, which symptom indicates to the nurse that he is experiencing respiratory distress? Respiratory rate of 62 breaths/minute 34.Child w/ scabies what would u do to prevent complication- cut the nails and put mitten on 35 The healthcare provider prescribes oxytocin synthetic (Pitocin), 10 units/L via IV drip to augment a client’s labor because she is experiencing a prolonged active phase. Because the client is receiving Pitocin, the nurse should closely monitor for which complication? Uterine Tetany 36. Hepatic encepahlopathy – Ammonia. 37. A client with a deep vein thrombosis is receiving a heparin protocol based on a target partial thromboplastin time (PPT) of 65 to 95 seconds. The client’s current PTT result is 35 seconds. What action should the nurse implement? Increasing the rate of the heparin infusion. Heparin acts to block the conversion of prothrombin, which will effectively inhibit the formation of new clots. To achieve a therapeutic heparinization and anticoagulation, the client’s PTT should be within the therapeutic target range of 65 to 95 seconds, so the nurse should increase the heparin infusion rate per protocol. 38. Female pt who being sexually and physically abused by bf and states I cant take it anymore= ask her if she is thinking about suicide 39. 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 40. Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mother’s vaginal
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. What action should the nurse take first? Perform fundal massage until firm 41. A 16-year-old female client who attempted suicide that morning is admitted to the psychiatric unit. To determine the seriousness of the adolescent’s suicide attempt which question is most important for the nurse to ask the family? How did she attempt to kill herself 42. What nursing intervention should the nurse include in the plan of care for a client following a bone marrow aspiration? Use of a compression dressing for firm pressure to the site. 43.A client is admitted to the emergency room because of an overdose of acetaminophen (Tylenol). Following gastric lavage, the nurse should expect to administer which medication? Answer Acetylcysteine (Mucomyst) The antidote for acetaminophen (Tylenol) is acetylcysteine (Mucomyst) 44. The nurse observes that a client who is to avoid any weight-bearing on the left leg is using a 3point crutch gait for ambulation. What is the best action for the nurse to initiate? Encourage continues use of the 3-point gait by the client 45.For increase magnesium level - Give calcium gluconate. 46.The practical nurse (PN) reports the patterns of urinary frequency and volume for several clients. Which finding necessaitates assessment by the RN? Voiding 50ml cloudy urine every hour. The symptoms of voiding cloudy urine, at frequent intervals, in small amounts is abnormal and may indicate urinary retention and infection. 47. Feedings for low albumin – Nepro, Ensure or TPN if pt is NPO. 48. Prioritrize question about tube feeding and how do you check it. Label, patient ID band, against the MAR, and the physicians order.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 49. A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium (Cs) loaded in a vaginal applicator. What action should the nurse implement? Wear a dosimeter film badge when in the client’s room 50. A client who suffered a stroke and is now on a ventilator receives nutritional supplements by the tube feedings three times a day. The nurse checks the client for a residual volume before administering the next feeding. Which statement best describes the rationale for this nursing intervention? Retention of feeding in the stomach increase the likelihood of regurgitation and aspiration. 51.Motion sickness – give transdermal scopolamine 4 hours before sailing in the sea for vacation. 52. Which client is at the greatest risk for suicide and should be managed with close observation? A widowed white male who is a veteran of the Korean War. 54. Know the best diet for Crohns Disease- select High protein, high calorie, low fat diet with
limited lactose (Grilled chicken sandwich, pasta, etc was answer) 55. Is concerned about the type of legal consequences that can result from breaching client
confidentiality. What source states the legal requirements nurses must follow to protect client confidentiality in a nurse-patient relationship? State Nurse Practice Acts 56. Which nursing intervention has the highest priority when completing discharge teaching for a
client with Helicobacter pylori (H.pylori) induced peptic ulcer disease (PUD)? Instruct the client to take all the antibiotics, proton pump inhibitors and Pepto-Bismol. 57. An older client is transferred to the rehabilitation unit with the diagnosis of cerebrovascular
accident with left sided hemiplegia. The nurse addresses the client from the right side, and the client
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) points to the left leg and states, ―There is someone’s leg in my bed!‖ What is the best response by the nurse? ―Your stroke has impaired your ability to recognize that it is your leg‖ 58. A mother tells the clinic that the healthcare provider wants her to begin introducing solid
foods to her 4-month-old infant. The nurse should recommend introducing foods in what order? (Arrange first on top and last on the bottom) Rice cereal, starined apple, strained green and strained pureed. 59. Cultural Stereotyping – know how to prevent that when you work with patient of different
ethnicity. 60. The nurse’s assessment of a client admitted with a diagnosis of diabetic ketoacidosis (DKA)
include: scant urinary output, serum potassium level of 2.5 mEq/l, blood pH of 7.26, temperature 98ºF, pulse 128 beats/minute, respirations 36 breaths/minute, and blood pressure 90/52. Which prescription is most important for the nurse to implement? Pottasium IV at 20 mEq/250 ml over 1 hour. 61. Hep A- preicteric phase- know S/S Initial flu-like stage, patients may experience respiratory
and gastrointestinal tract symptoms, which may include malaise, fatigue, myalgia) 62. Fluids are restricted for a 4-year-old boy with acute poststreptococcal glomerulonephritis (AP
SGN). Which nursing intervention makes the fluid restriction less obvious to the child? Play a game of tea party and serve the allowed amount of liquids in small medicine cups. 63. The nurse tests a client’s visual acuity and determines that the uncorrected vision is 20/100 in
the right eye and 20/80 in the left eye. What does this finding indicate? Difficulty visualizing objects at a distance also known as myopia. 64. The nurse knows that the blood urea nitrogen (BUN) can be expected to change as one ages.
Which statement best explains this expected change? BUN increases because of a decrease in renal functioning and a decrease in cardiac output.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 65. An infant has a medical diagnosis of tracheosophageal fistula (TEF). What nursing
intervention is indicated for his infant prior to surgical repair? Keep suction equipment available at all times. 66. Mechanical life support- equipment used 67. An Elderly man is having trouble urinating and unsteady he uses a wheelchair to walk to the
bathroom what should the nurse implement? provide a raised toilet seat. 68. The healthcare provider hands a newborn to the circulating nurse during a cesarean delivery.
What action should the nurse implement first? Dry the infant under a warming unit. 69 Treatment for VF- Vasopressin 70.A client is known to have an irregular respiratory rate with periods of apnea lasting 10 to 15 seconds. Currently, the nurse counts 22 respiratory cycles in a 30 second interval followed by an apneic period. What intervention should the nurse implement? 71. A patient with inverted nipples what should the nurse do for the client? provide a breast shield. 72. Anterior Fontanel- to protect, sit baby up 73. The alarm of a client’s pulse oximeter sounds and the nurse notes that the oxygen saturation rate is indicated at 85%. What action should the nurse take first? Administer oxygen by face mask. 74. A client who developed Syndrome of inappropriate Antidiuretic Hormone (SIADH) associated with small cell carcinoma of the lung is preparing for discharge. When teaching the client about selfmanagement with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the healthcare provider? 75. Prioritrize question about tube feeding and how do you check it the answers are label, patient ID band, against the MAR, and the physicians order. 76. 147. Community Planning Interventions for Mothers- most beneficial to provide vitamins to high
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) risk pregnant mothers in the area 77. Which approach is best for the nurse to use when communicating with a client with amyotrophic lateral sclerosis (ALS) Demonstrate a positive caring a demeanor 78. What action should the nurse implement first when delegating nursing activities to an unlicensed assistive personnel (UAP) Answer: Evaluate the experience of the UAP 79. At 28 wks gestation- pulse increases is normal 80. The nurse is triaging victims of a tornado that hit a housing area outside of town. Which client would the nurse issue a black disaster tag to? A 59-year old 81. Genital herpes medication – Acyclovir. 82. An adult male who admits to abusing IV drugs obtains the results of HIV testing. When informed that the results are positive, he states that he does not want his wife to know. What action should the nurse take? Counsel the client about the importance of notifying his sexual partner. 83. The nurse observes that a client who is to avoid any weight-bearing on the left leg is using a 3point crutch gait for ambulation. What is the best action for the nurse to initiate? Encourage continues use of the 3-point gait by the client 84. 5yr old burn victim has pot of hot liquid fall on him,what should nurse tell mother to do first- nurse should tell mother to remove clothing and place in cool bath 85. When planning nursing care for immobilized clients, the nurse should consider which physiological alterations that frequently occur with immobility? (Select all that apply.) Urinary stasis, Venous pooling and Bony demineralization. 86. Secondary polycythemia – increases stimulation of red blood cells, increase exposure 87. A female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) severe, chonic pain. Which interdisciplinary team member should the nurse consult to assist the client? Pain specialist 88. A one-day old neonate is awaiting surgical correction of a myelomeningocele. During the preoperative period what is the priority nursing intervention? Observe for CNS infection related to sac trauma 89. Chest tube disconnect( Put the end of the tube in a sterile bottle fill with Normal saline and connect back to patient) 90. A 50 year old male client has just been informed that he will require open heart surgery. He tells the nurse, ―This will change my whole life. Nothing will ever be the same again.‖ What action should the nurse implement? Encourage the client to discuss his perceptions of the changes his life will undergo. 91. Client has a Lithium Rx level of 0.54 (know Lithium ranges- Low, so the answer is to ask client if they have been taking their medication everyday 92. The nurse is assessing a client with hypothyroidism and knows that these clients are at risk for myxedema coma. What symptoms indicate that the client is developing this condition? A Hypothermia, decreased cardiac output, and decreased respiratory functioning 93. In establishing goals for the client’s plan of care, which information is most important for the nurse to consider? Nursing diagnoses. 94. You conduct CPR on intubated client and detects palpable pulse during 2-min cycle of chest compressions, absent breath sounds over left lung, what to do Next- prepare for the endotracheal tube to be repositioned 95. Mother believes baby is evil- mother exhibiting delusional thoughts
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 96. Following a precipitous labor, a client has a continuous trickling of bright red blood from her vagina. Her uterus is firm and her vital signs are within normal limits. The nurse determines that the client’s symptoms may indicate which condition? A cervical laceration 97. Pre bed bath assessment – what would you say to CNA on the activity level of the pt 98. The nurse is administering sodium polystyrene sulfonate (Kayexalate) to a client in acute renal failure. Which normal finding indicates that the medication has been effective? Serum potassium level of 4.3 mEq/L. 99. Pressure Ulcer: Turning the pt n noticing no pressure, redness, and pt doesn’t complain of pain 100. Before administering a prescribed dose of tetracycline (ACHROMYCIN), what serum lab test should the nurse monitor? Creatine. 101. Diabetes Insipidus – fluid imbalance and that hypophysectomy leads to DI and the patho 102. An infant admitted to the neonatal intensive care unit is tachypneic, tachycardia, and has bounding brachial pulses. The healthcare provider suspects that the infant has coarctation of the aorta. Which intervention is most important for the nurse to include in this infant’s plan of care? Monitor for congestive heart failure 103. The nurse is assessing an unresponsive client who ingested an unknown number of meperidine (DEMOROL) 50mg tablets. Naloxone (NARCAN) 0.4mg IV is administered, and the client is now responding to verbal stimuli. Which finding in the next hour requires immediate action by the nurse? Difficulty in arousing. 104. The nurse is caring for a client in the Medical Intensive Care Unit. What problem is a client probably experiencing who has an easily obliterated radial pilse and below-normal pressures, including
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) blood pressure (BP), central venous pressure (CVP), pulmonary artery pressure (PAP), and pulmonary under pressure? Hypovolemic shock. 105. Cystic Fibrosis – (Autosomal recessive) know the inheritance, what are the chances the children will get it if both parents are carriers? Cystic fibrosis is an inherited chronic disease that affects the lungs and digestive system, diagnosis in child before 1yr old, seen in whites, condition is inherited in an autosomal recessive pattern, which means both copies of the gene in each cell have mutations. The parents of an individual with an autosomal recessive condition each carry one copy of the mutated gene, but they typically do not show signs and symptoms of the condition. When both parents carry mutation, each child has a 1-in-4 chance of having CF 106. PRI interval - depolarization and repolarization 107. K+ and lasix… it’s not potassium sparing – Aldactone 109. The charge nurse is implementing a quality assurance policy and accompanies a nurse while administering medications. The nurse identifies a male client by asking him to state his name prior to administering the medication.Which action should the charge nurse implement? Tell the nurse in a private area that the clients identification was incomplete. 110. Which surveillance clues are specific potential indicators of a bioterrorism attack? (Select all that apply.) Geographic clustering of client illnesses and Unusual age distributions for a common disease. 111. While assigned to care for clients on a surgical unit, the nurse receives a personal phone call about a family emergency that requires the nurse to leave immediately. What action by the nurse is most important? Notify the charge nurse of the situation and of the need and leave immediately.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 112. A female client is instructed to do Kegel exercises. What statement indicates to the nurse that the client understands how to perform these exercises? When I urinate I should tighten those muscles and stop the flow of urine for 10 seconds and repeat this 5 to 10 times 113. Which is the highest for carcinogenic shock= pt whom had a traumatic amputation from the groin down, there one of the choice a pt w/ gunshot wound to the chest and abdomen HESI HINT: if Cardiogenic shock exits in the presence of pulmonary edema (ex. from pump failure), position pt to reduce venous return (high fowler’s w/ legs down) in order to reduce further venous return to the left ventricle. 114. When obtaining a health history a male client tells the nurse that, he has become impotent. What part of his health information is likely to be most significant to the sexual dysfunction he is experiencing? The client Was diagnosed with diabetes mellitus 10 years ago 115. Coreg Risk - contraindicated in asthma pt. 116. TURP – assessment for pain- Transurethral resection of the prostate (TURP) is a type of prostate surgery done to relieve moderate to severe urinary symptoms caused by an enlarged prostate. During TURP, a combined visual and surgical instrument (resectoscope) is inserted through the tip of your penis and into the tube that carries urine from your bladder (urethra). The urethra is surrounded by the prostate. Using the resectoscope, your doctor trims away excess prostate tissue that's blocking urine flow. benign prostatic hyperplasia (BPH 117. Drug: Percodia - drug containing aspirin – It also has oxycodone (pain) and aspirin (salicylate) 118. Pathophysiology of Guillian Barré Syndrome!!! - Guillain-Barre Syndrome is a disorder in which
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) your body's immune system attacks the nerves. Weakness and tingling in the extremities are usually the first symptoms. These sensations can quickly spread, eventually paralyzing your whole body. In its most severe form, Guillain-Barre syndrome is a medical emergency requiring hospitalization. The exact cause of Guillain-Barre syndrome is unknown, but it is often preceded by an infectious illness such as a respiratory infection or the stomach flu. There's no known cure for Guillain-Barre syndrome, but several treatments can ease symptoms and reduce the duration of the illness. Most people recover from Guillain-Barre syndrome, though some may experience lingering effects from it, such as weakness, numbness or fatigue. 119. Know which position for a pt that had bone marrow taken out. BM aspiration site: iliac crest. 120. A client admitted to the hospital is suspected of having meningitis. The nurse should plan to prepare the client for which diagnostic test? Lumbar puncture 121. The nurse is performing an intake interview at a prenatal clinic. Which planned activities described by the client who is at 6 weeks gestations will the nurse investigate first? Supervision of the renovation of an old house the family just purchased due to teratogen defect. 122. A client in acute renal failure has a serum potassium level of 6.3 mEq/L. What medication can the nurse expect the healthcare provider to prescribe? Kayexalate retention enema. 123. The nurse is administering oxygento a client with pulmonary edema when a family member asks the nurse why the client needs oxygen. Which pathophysiological mechanism should the nurse explain to his family member? Fluid collects in the chest cavity and keeps the lungs from expanding. 124. During shift report, the nurse learns that a postoperative client has atelectasis. What nursing diagnosis should the nurse expect to include in the clients plan of care? Impaired gas exchange.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 125. Fibrocystic Breast = Answer = Caffeine- the disease is painful, lumpy breasts Some women feel that eating chocolate, drinking caffeine, or eating a high-fat diet can cause their symptoms, but there is no clear proof of this, worse right before the menstrual period. Treatment- acetaminophen or ibuprofen, Use heat or ice on the breast, wear a well-fitting bra 126. Triage - put in order: 1. wondering man, 2. woman w/blanket, 3. man holding baby, 4. parents looking for son. 127. A hospitalized client’s bronchoscopy specimen culture result indicates the presence of the Mycobacterium tuberculosis organism. Which intervention is most important for the nurse to implement? Put the client in a room with negative airflow system. 128. A client with gestational diabetes at 39-weeks gestation is in the second stage of labor. After delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? Assist the client to sharply flex her thighs up against the abdomen 129. While assessing a client with wrist restraints the nurse first slides two fingers under the restraints and then notes that the ties are secured to the side rail using a quick-release tie. What action should the nurse implement? Reposition the restraints ties, securing them to the bed frame 130. While reporting a client’s blood glucose results to the nurse the LPN states that, the glucometer was not calibrated prior to use because the report given by the night shift staff ran late. What action is most important for the nurse to perform? Advise the LPN of the implications involved by not calibrating the glucometer 131. Patient is on radioactive chemotherapy = have the nurse be in the pt room for 30min with cluster care (this was a hard one – just look up nursing care for pt on chemo) 132. Understand the reason for Z track method( it use for IM) – prevent leakage
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 133. A client from a nursing home is admitted with urinary sepsis and has a single-lumen, peripherallyinserted central catheter (PICC). Four medications are prescribed for 9:00 a.m.and the nurse is running behind schedule. Which medication should the nurse administer first : (Zosyn) over 30 minutes q8 hours. 134. During a family baseball game, an adult male is hot on the head with a bat, and he is suspected of sustaining an epidural bleed. What Is the most important information for the emergency center nurse to obtain form the client’s spouse, who witnessed his injury? ―Was your husband knocked out by the blow‖ 135. An 86-year-old female client complains to the nurse that she does not like to eat as much as she used to because things taste differently to her now that she is older. The nurse’s response should be based on which fact? A loss of appetitie often occurs in older adults as a result of a decreased sense of smell. 136. A client with a compound fracture of the left ankle is being discharged with a below-theknee cast. Before being discharged, the nurse should provide the client with what instructions? 137. A 9-month old child with diarrhea, vomiting and malaise= Ask the mother on the onset of symptoms 138. An infant who is jittery and I think it said crying, what should the nurse do firs t= Assess blood glucose. 139. A client in acute renal failure has serum potassium of 7.5mEq/L. based on this finding, the nurse should anticipate implementing which action? Administer a retention enema of Kayexalate
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 140. A pt with COPD who state that he is using is inhaler right, what should the nurse indicate the pt is not using the inhaler properly= Pt states that he only uses the inhaler when he is having respiratory distress 141. CPR for a pregnant lady= will give Heimlich w/ chest compression HESI HINT: At 20wks gestation & beyond, the gravid uterus should be shifted to the left by placing the women in a 1530 degree angled, left lateral position or by using a wedge under her right side to tilt her to her left 142. Pyelonephritis symptoms - elevates temperature 143. The nurse observes tha a client has received 250 ml of 0.9% normal saline through the IV line in the last hour. The client is now tachypneic, and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action should the nurse implement? Decrease the saline keep-open rate. The nurse should decrease the rate of the IV solution to keep-open rate to avoid further fluid volume overload while awaiting a change in prescription from the healthcare provider. 144. On osteoporosis= weight bearing physical activity 145. Education about DM= to increase knowledge on the disease process and treatment 146. Cerebral palsy – prognosis neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination. Cerebral palsy doesn’t always cause profound disabilities. While one child with severe cerebral palsy might be unable to walk and need extensive, lifelong care, another with mild cerebral palsy might be only slightly awkward and require no special assistance. Supportive treatments, medications, and surgery can help many individuals
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) improve their motor skills and ability to communicate-symptoms, paraplegia, quadriplegia, hemiplegia, seizure, retardation, learning issues, behavior, bladder bowel bone issues 147. A 60yrs Pt with advance prostate cancer which response indicate that he accept his prognosis or illness = Pt admits that he has support of family & friends – use your judgment on this one) Community primary prevention 148. The risk for metabolic shock syndrome – Toxic Shock Syndrome 149. Side effects of aspirin- (Reye syndrome in kids) Overdose may happen if your kidneys do not work correctly or when you are dehydrated. Signs include ringing in the ears, deafness, hyperactivity, dizziness,drowsiness, seizures, coma, Treatment-fluids, activated charcoal, laxative, IV of potassium, sodium bicarb 150. The nurse is reviewing the medical history of a client who is scheduled for a parathyroidectomy. Which disorder in the client’s history is most likely to be impacted by the surgery? Osteoporosis. 151. A female client reports that she drank ¾ of a liter of a solution to cleanse her intestines for a colonoscopy. How many ml of fluid intake should the nurse document? (Enter numeric value only. If rounding is required, round to the nearest whole number.) 152. First convert the liter to ml: 1L × 1000 = 1000ml. Next multiply 1000 by ¾ = 750 ml. 152. The nurse is instructing a client who is newly diagnosed with Addison's disease. Which of the following should the nurse include when discussing the manifestations of this disease with the client? Hyperkalemia, hyponatremia, and hypoglycaemia. 153. A client is admitted to the nursing unit with a possible bowel obstruction. The nurse osculates
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) high-pitched bowel sounds in the upper quadrants of the client’s abdomen. What is the significance of this finding? Provides data about the location of the obstruction. High-pitched bowels sounds may be ausculated above the bowel obstruction early in the obstructive process as peristalsis initially increases, and may help determine the location of the obstruction. 154. Inserting NG tube in client that becomes cyanotic- withdraw NG tube (1 st action) 155. Client in labor, you call the provider and he has slurred words, loud noise in background, and seems intoxicated- you should contact the healthcare provider’s associate, not the medical director 156. After a sexual assault, the nurse collects evidence for 6hrs then should do what- maintain possession of the evidence collection kit at all times 157. A 93 year-old male client is brought to the emergency room by a group of fraternity brothers after a hazing event at the university. The client arrives with a blood alcohol level (BAL) of 3.8 and a Glasgow Coma Scale of 3. Which action should the nurse implement first? Initiate IV access using Lactated Ringer’s solution 1000ml with thiamine 100mg. Hydrating the client and providing thiamine (Vitamin B) to prevent neurological insult from ethanol toxicity are the highest priority interventions. 158. The nurse is preparing to administer vancomycin (Vancocin) 500mg in 200 ml of D6W, and based on the manufacturer’s recommendation, the nurse plans to administer the dosage over 90 minutes. The secondary infusion pump should be set to administer how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number.) 133. 200ml of the antibiotic is to infuse over 90minutes. 200ml divided by 90minutes/hour equals 133.33=133ml/hour.
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ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 159. BNP prescribed diuretic 500 indicates HF 160. Pancreatitis maintain IV: 125 ml/hr Help
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