RN HESI EXIT EXAM V1
A client with postpartum depression, who is admitted to the behavioral health unit,
refuses to leave her room or eat meals. In addition to maintaining physical safety,
which short-term goal should the nurse include in the plan of care?
A. Sleeps at least 6 hours per night
B. Consumes 3 meals and 1500 mL of fluid per day
C. Engages in one client to client interaction daily
D. Attends one group activity per day
Answer:
D. Attends one group activity per day
A 7-year old is admitted to the hospital with persistent vomiting, and a nasogastric
tube attached to low intermittent suction is applied. Which finding is most
important for the nurse to report to the healthcare provider?
A. Shift intake of 640mL IV fluids plus 30mL PO ice chips
B. Serum pH of 7.45
C. Gastric output of 100 mL in the last 8 hours
D. Serum potassium of 3.0 mg/dL
Answer:
D. Serum potassium of 3.0 mg/dL
A male client approaches the nurse with an angry expression on his face and raises
his voice, saying “My roommate is the most selfish, self-centered, angry person I
have ever met and if he loses his temper one more time with me, I am going to
punch him out!” The nurse recognizes that the client is using which defense
mechanism?
A. Splitting
B. Projection
C. Rationalization
D. Denial
Answer:
B. Projection
The nurse is teaching the client about home care after surgery for an ileal conduit
placement. When reviewing the information, which statement should the nurse
recognize as needing additional education?
A. report presence of mucus in the urine
B. Empty pouch when it is half full
C. Look at the stoma when replacing appliance
D. Anticipate shrinking of the stoma
Answer:
B. Empty pouch when it is half full
A nurse who is working in the emergency department triage area is presented with
four clients at the same time. The client presenting with which symptoms requires
the most immediate intervention by the nurse?
A. One inch bleeding laceration on the chin of crying 5 year old
B. Low grade fever, headache and malaise for the past 72 hours
C. Chest discomfort one hour after consuming a large, spicy meal
D. Unable to bear weight on the left food, with swelling and bruising
Answer:
C. Chest discomfort one hour after consuming a large, spicy meal
When the nurse enters the room of a male client who was admitted for a fractured
femur, his cardiac monitor displays a normal sinus rhythm, but he has no
spontaneous respirations and his carotid pulse is not palpable. Which intervention
should the nurse implement?
A. Analyze the cardiac rhythm in another lead
B. Obtain a 12-lead electrocardiogram
C. Observe for swelling at the fracture site
D. Begin chest compressions at 100/minute
Answer:
D. Begin chest compressions at 100/minute
The nurse identifies the presence of clear fluid on the surgical dressing of a client
who just returned to the unit following lumbar spinal surgery. Which action should
the nurse implement immediately?
A. Change the dressing using a compression bandage
B. Test the fluid on the dressing for glucose
C. Document the findings in the electronic medical record
D. Mark the drainage area with a pen and continue to monitor
Answer:
B. Test the fluid on the dressing for glucose
After administering a 12 ounce can of nutritional supplement, 3 teaspoons of
medication, and 120 mL of water, the nurse should document the client’s fluid
intake as how many mL?
Answer:
495
The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility
prior to discharge. Which behaviors indicates the client understands how to
maintain balance safely? (Select all that apply)
A. Brings a heavy can close to body before lifting
B. Leans forward to pull on a pan from a high shelf
C. Locks knees while preparing food on the counter
D. Bends from the waist to pick trash off the floor
E. Widens stance while working near the sink
Answer:
C. Locks knees while preparing food on the counter
D. Bends from the waist to pick trash off the floor
A client with rheumatoid arthritis (RA) starts a new prescription for etanercept
subcutaneously once weekly. The nurse should emphasize the importance of
reporting which problem to the healthcare provider?
A. Joint stiffness
B. Persistent fever
C. Headache
D. Increased hunger and thirst
Answer:
A. Joint stiffness
RN HESI EXIT EXAM V2
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. Signs of addiction to opioid pain medication
B. Information about non-pharmaceutical pain relief measures
C. Referral for social services for the child and family
D. Instructions about how much fluid the child should drink
Answer:
D. Instructions about how much fluid the child should drink
When conducting diet teaching for a client who was diagnosed with hypertension,
which foods should the nurse encourage the client to eat?
A. Fruits without sauce
B. Canned soup
C. Fresh or frozen vegetables without sauce
D. Cottage cheese
E. Pickled olives
Answer:
A. Fruits without sauce
C. Fresh or frozen vegetables without sauce
D. Cottage cheese
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. Postpone the feeding until the infant’s vital signs are stable
B. Continue the insertion since this is a typical response
C. Insert the feeding tube into the infant’s nasal passage
D. Pause and monitor for a continued drop of the heart rate
Answer:
A. Postpone the feeding until the infant’s vital signs are stable
A client with bacterial meningitis is receiving phenytoin. Which assessment finding
indicates to the nurse that the client is experiencing a therapeutic response to the
phenytoin?
A. Decrease in intracranial pressure and cerebral edema
B. Increased time of ambulation between periods of rest
C. Normal electroencephalogram after drug administration
D. Absence of seizure activity for the duration of treatment
Answer:
D. Absence of seizure activity for the duration of the treatment
The nurse is assessing a client’s breath sounds. Which medication from the client’s
prescriptions will have the most positive effect on this respiratory finding?
Sound: wheezing
A. Chloroquine
B. Enalapril
C. Albuterol
D. Losartan
Answer:
C. Albuterol
The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility
prior to discharge. Which behaviors indicate the client understands how to maintain
balance safely?
A. Bring a heavy can close to body before lifting
B. Locks knees while preparing food on the counter
C. Widens stance while working near the sink
D. Bends from the waist to pick trash off the floor
E. Leans forward to pull a pan from a high shelf
Answer:
A. Brings a heavy can close to body before lifting
C. Widens stance while working near the sink
A school-aged child who weighs 42 pounds receives a post-tonsillectomy prescription
for promethazine 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?
Answer:
-convert weight to kg: 42/2.2 = 19.09 kg
-dose/kg = 0.5×19.09 = 9.5454mg
-amount per ml:
25mg —- in 1ml
9.5mg —-in X ml
X = 9.5 x1/25 = 0.38 = 0.4 mL
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?
A. Assess skin elasticity of the stump
B. Observe for swelling around the stump
C. Note amount and color of wound drainage
D. Evaluate closest proximal pulse
Answer:
D. Evaluate closest proximal pulse
During shift report, the charge nurse receives notice of several problems. Which
problem should the nurse address first?
A. The census report has not been completed
B. A client’s wife has asked to speak with the charge nurse
C. One staff member has not reported to work
D. A bucket of water was spilled in the hallway
Answer:
D. A bucket of water was spilled in the hallway
An older client is admitted to the hospital because of recurring transient ischemic
attacks. Neurological serial assessments for the past 24 hours were within normal
limits. One day after admission, the client suddenly becomes confused and
combative indicating impaired mental status (IMS). What intervention should the
nurse implement first?
A. Document neurologic changes
RN HESI EXIT EXAM V3
- A 64-year-old client scheduled for surgery with a general anesthetic refuses to
remove a set of dentures prior to leaving the unit for the operating room. What
would be the most appropriate intervention by the nurse?
A) Explain to the client that the dentures must come out as they may get lost or
broken in the operating room
B) Ask the client if there are second thoughts about having the procedure
C) Notify the anesthesia department and the surgeon of the client’s refusal
D) Ask the client if the preference would be to remove the dentures in the operating
room receiving area
Answer:
D: Ask the client if the preference would be to remove the dentures in the operating
room receiving area - The nurse has been teaching adult clients about cardiac risks when they visit the
hypertension clinic. Which form of evaluation would best measure learning?
A) Performance on written tests
B) Responses to verbal questions
C) Completion of a mailed survey
D) Reported behavioral changes
Answer:
D: Reported behavioral changes - The nurse is planning care for an 18 month-old child. Which action should be
included in the child’s care?
A) Hold and cuddle the child frequently
B) Encourage the child to feed himself finger food
C) Allow the child to walk independently on the nursing unit
D) Engage the child in games with other children
Answer:
B: Encourage the child to feed himself finger food - A partner is concerned because the client frequently daydreams about moving to
Arizona to get away from the pollution and crowding in southern California. The
nurse explains that
A) Such fantasies can gratify unconscious wishes or prepare for anticipated future
events
B) Detaching or dissociating in this way postpones painful feelings
C) This conversion or transferring of a mental conflict to a physical symptom can
lead to marital conflict
D) To isolate the feelings in this way reduces conflict within the client and with
others
Answer:
A: Such fantasies can gratify unconscious wishes or prepare for anticipated future
events - An appropriate goal for a client with anxiety would be to
A) Ventilate anxious feelings to the nurse
B) Establish contact with reality
C) Learn self-help techniques
D) Become desensitized to past trauma
Answer:
C: Learn self-help techniques
- While the nurse is administering medications to a client, the client states “I do
not want to take that medicine today.” Which of the following responses by the
nurse would be best?
A) “That’s OK, its all right to skip your medication now and then.”
B) “I will have to call your doctor and report this.”
C) “Is there a reason why you don’t want to take your medicine?”
D) “Do you understand the consequences of refusing your prescribed treatment?”
Answer:
C: “Is there a reason why you don’t want to take your medicine?” - While caring for a client, the nurse notes a pulsating mass in the client’s peri
umbilical area. Which of the following assessments is appropriate for the nurse to
perform?
A) Measure the length of the mass
B) Auscultate the mass
C) Percuss the mass
D) Palpate the mass
Answer:
B: Auscultate the mass - A client is admitted to the hospital with a history of confusion. The client has
difficulty remembering recent events and becomes disoriented when away from
home. Which statement would provide the best reality orientation for this client?
A) “Good morning. Do you remember where you are?”
B) “Hello. My name is Elaine Jones and I am your nurse for today.”
C) “How are you today? Remember, you’re in the hospital.”
D) “Good morning. You’re in the hospital. I am your nurse Elaine Jones.”
Answer:
D: “Good morning. You’re in the hospital. I am your nurse Elaine Jones.”
- The nurse is teaching the parents of a 3 month-old infant about nutrition. What
is the main source of fluids for an infant until about 12 months of age?
A) Formula or breast milk
B) Dilute nonfat dry milk
C) Warmed fruit juice
D) Fluoridated tap water
Answer:
A: Formula or breast milk - The family of a 6 year-old with a fractured femur asks the nurse if the child’s
height will be affected by the injury. Which statement is true concerning long bone
fractures in children?
A) Growth problems will occur if the fracture involves the periosteum
B) Epiphyseal fractures often interrupt a child’s normal growth pattern
C) Children usually heal very quickly, so growth problems are rare
D) Adequate blood supply to the bone prevents growth delay after fractures
Answer:
B: Epiphyseal fractures often interrupt a child”s normal growth pattern
RN HESI EXIT EXAM V4
- The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which
nursing intervention is appropriate for this child?
A) Make certain the child is maintained in correct body alignment.
B) Be sure the traction weights touch the end of the bed.
C) Adjust the head and foot of the bed for the child’s comfort
D) Release the traction for 15-20 minutes every 6 hours PRN.
Answer:
A: Make certain the child is maintained in correct body alignment. - The nurse is assessing a healthy child at the 2 year check up. Which of the
following should the nurse report immediately to the health care provider?
A) Height and weight percentiles vary widely
B) Growth pattern appears to have slowed
C) Recumbent and standing height are different
D) Short term weight changes are uneven
Answer:
A: Height and weight percentiles vary widely - The parents of a 2 year-old child report that he has been holding his breath
whenever he has temper tantrums. What is the best action by the nurse?
A) Teach the parents how to perform cardiopulmonary resuscitation
B) Recommend that the parents give in when he holds his breath to prevent anoxia
C) Advise the parents to ignore breath holding because breathing will begin as a
reflex
D) Instruct the parents on how to reason with the child about possible harmful
effects
Answer:
C: Advise the parents to ignore breath holding because breathing will begin as a
reflex
- The nurse is assessing a client in the emergency room. Which statement suggests
that the problem is acute angina?
A) “My pain is deep in my chest behind my sternum.”
B) “When I sit up the pain gets worse.”
C) “As I take a deep breath the pain gets worse.”
D) “The pain is right here in my stomach area.”
Answer:
A: “My pain is deep in my chest behind my sternum.” - The nurse is assessing the mental status of a client admitted with possible
organic brain disorder. Which of these questions will best assess the function of the
client’s recent memory?
A) “Name the year.” “What season is this?” (pause for answer after each question)
B) “Subtract 7 from 100 and then subtract 7 from that.” (pause for answer) “Now
continue to subtract 7 from the new number.”
C) “I am going to say the names of three things and I want you to repeat them after
me: blue, ball, pen.”
D) “What is this on my wrist?” (point to your watch) Then ask, “What is the purpose
of it?”
Answer:
C: “I am going to say the names of three things and I want you to repeat them after
me: blue, ball, pen.”
- In planning care for a 6 month-old infant, what must the nurse provide to assist
in the development of trust?
A) Food
B) Warmth
C) Security
D) Comfort
Answer:
C: Security - A nurse has just received a medication order which is not legible. Which
statement best reflects assertive communication?
A) “I cannot give this medication as it is written. I have no idea of what you mean.”
B) “Would you please clarify what you have written so I am sure I am reading it
correctly?”
C) “I am having difficulty reading your handwriting. It would save me time if you
would be more careful.”
D) “Please print in the future so I do not have to spend extra time attempting to
read your writing.”
Answer:
B) “Would you please clarify what you have written so I am sure I am reading it
correctly?”
- What is the most important consideration when teaching parents how to reduce
risks in the home?
A) Age and knowledge level of the parents
B) Proximity to emergency services
C) Number of children in the home
D) Age of children in the home
Answer:
D: Age of children in the home - A 35 year-old client with sickle cell crisis is talking on the telephone but stops as
the nurse enters the room to request something for pain. The nurse should
A) Administer a placebo
B) Encourage increased fluid intake
C) Administer the prescribed analgesia
D) Recommend relaxation exercises for pain control
Answer:
C: Administer the prescribed analgesia - While caring for a toddler with croup, which initial sign of croup requires the
nurse’s immediate attention?