HESI Exit Exam Fundamental with Answers and Rationale (Complete 100% Helpful Guide)

HESI Exit Exam Fundamental with Answers and Rationale HESI Exit Exam Fundamental 1. A nurse is teaching staff members about the legal terminology used in child abuse. What definition of battery should the nurse include i ...

HESI Exit Exam Fundamental with Answers and Rationale HESI Exit Exam Fundamental 1. A nurse is teaching staff members about the legal terminology used in child abuse. What definition of battery should the nurse include in the teaching? 2. Which nursing interventions require a nurse to wear gloves? ( Select all that apply.) 3. A nurse is caring for a client with hemiplegia who is frustrated. How can the nurse motivate the client toward independence? 4. A health care provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker? 5. To prevent footdrop in a client with a leg cast, the nurse should: 6. What should the nurse include in dietary teaching for a client with a colostomy? 7. A client with respiratory difficulties asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to: 8. A 2-year-old child admitted with a diagnosis of pneumonia was administered antibiotics, fluids, and oxygen. The child's temperature increased until it reached 103° F. When notified, the health care provider determined that there was no need to change treatment, even though the child had a history of febrile seizures. Although concerned, the nurse took no further action. Later, the child had a seizure that resulted in neurological impairment. Legally, who is responsible for the child's injury? 9. On the third postoperative day following a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. What is the best initial approach that the nurse should take when interacting with this client? 10. While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. This condition is known as: 11. The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms? 12.A nurse identifies that an older adult has not achieved the desired outcome from a prescribed proprietary medication. When assessing the situation, the client shares that the medication is too expensive and the prescription was never filled. What is an appropriate nursing response? 13. A client with heart failure is on a drug regimen of digoxin (Lanoxin) and furosemide (Lasix). The client dislikes oranges and bananas. Which fruit should the nurse encourage the client to eat? 14. What is the best nursing intervention to minimize perineal edema after an episiotomy? 15. A client is admitted to the hospital after a motor vehicle accident with multiple abrasions and lacerations to the chest and all four extremities. The nurse helps the client select food items for the upcoming meals and recommends: 16. A client newly diagnosed with myasthenia gravis is concerned about fluctuations in physical condition and generalized weakness. When caring for this client it is most important for the nurse to plan to: 17. An older client's colonoscopy reveals the presence of extensive diverticulosis. What type of diet should the nurse encourage the client to follow? 18. A client with a left ureteral calculus is scheduled for a transurethral ureterolithotomy. During the preoperative assessment, the nurse expects the client to report pain: 19. A client is cautioned to avoid vitamin D toxicity while increasing protein intake. Which nutrient selected by the client indicates to the nurse that the dietary teaching is understood? 20. The nurse teaches a client who developed degenerative joint disease of the vertebral column positioning techniques, including turning from back to side, keeping the spine straight. The nurse explains that the least effort will be exerted if the client crosses the arm over the chest and: 21. A client was recently diagnosed with a cancerous lesion of the mouth. What should the nurse ask when analyzing the client's need for health education in relation to this health problem? 22. A nurse is teaching a class about hepatitis, specifically hepatitis A. Which food should the nurse explain most likely will remain contaminated with the hepatitis A virus after being cooked? 23. A nurse is caring for a client that has been admitted with right sided heart failure. The nurse notes that the client has dependent edema around the area of the feet and ankles. In order to characterize the severity of the edema, the nurse presses the medial malleolus area and notes an 8 mm depression after release. This nurse understands that the edema should be documented as: 24. A mother whose newborn infant son has a cleft lip and palate asks how to feed her baby because he has difficulty suckling. What information should the nurse provide concerning safe feeding technique for this infant? 25. A client who has been in a coma for two months is being maintained on bed rest. The nurse concludes that to prevent the effects of shearing force, the head of the bed should be maintained at an angle of: 26. A client is receiving a 2-gram sodium diet. The family asks whether they can bring snacks from home. The nurse suggests that they bring foods low in sodium such as: 27. A client is hospitalized for the treatment of thrombophlebitis. What should the nurse include in the client's teaching plan related to how to prevent thrombophlebitis? 28. Discharge planning for an ambulatory client with Parkinson disease (PD) includes recommending equipment for home use that will help with activities of daily living. To foster independence, the nurse should promote the use of: 29. A client's serum albumin value is 2.8 g/dL. Which food selected by the client indicates that the nurse's dietary teaching is successful? 30. A nurse in a rehabilitation center teaches clients with quadriplegia to use an adaptive wheelchair. Why is it important that the nurse provide this instruction? 31. Why is it important for a nurse in the prenatal clinic to provide nutritional counseling to all newly pregnant women? 32. A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? (Select all that apply.) 33. A client is experiencing stomatitis as a result of chemotherapy. Which nursing action is most appropriate when caring for this client? 34. A nurse is monitoring a client with renal failure for signs of fluid excess. Which finding does the nurse identify as inconsistent with fluid excess? 35. When assisting a client who had a total hip replacement onto the bedpan on the first postoperative day, the nurse should instruct the client to: 36. Which alternative therapy may be beneficial for the nurse to discuss with a client who has terminal bone cancer? 37. A nurse reviews the prescribed treatment with the parents of an infant born with bilateral clubfeet. Which parental statement indicates to the nurse that further education is required? 38. fter surgery for a fractured hip, a client states, "I don't remember when I have ever been so uncomfortable." The nurse should: 39. A client with pulmonary tuberculosis discusses the dietary plan with the nurse. The nurse expects that the type of diet that will be prescribed for the client is: 40. A nurse is evaluating a client's response to fluid replacement therapy. Which clinical finding indicates adequate tissue perfusion to vital organs? 41. A preschooler is admitted with a diagnosis of acute glomerulonephritis. The child's history reveals a 5-lb weight gain in 1 week and periorbital edema. How can the nurse obtain the most accurate information on the status of the child's edema? 42. A 75-year-old female client tells the nurse that she read about a vitamin that may be related to aging because of its relationship to the structure of cell walls. The nurse determines that the client is probably referring to: 43. A nurse is teaching a postoperative client about the importance of vitamin C for wound healing. Which food selection demonstrates the client is applying the information correctly? 44. A hospitalized 7-year-old boy wakes up crying because he has wet his bed. It is most appropriate for the nurse to: 45. What intervention is included in the nursing care plan for a 4-month-old infant with tetralogy of Fallot and heart failure? 46. A client who has intermittently been having painful, swollen knee and wrist joints during the past three months is diagnosed with rheumatoid arthritis. What type of diet should the nurse expect the health care provider to prescribe? 47. The nurse is providing care for a client that is on bed rest. The nurse can prevent skin breakdown for this client by: 48. A client is admitted to the hospital for the medical management of burns over 18% of the body's surface. What should the nurse teach the client to help manage pain during dressing changes? 49. A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates the need for further instruction? 50. Before discharging a 9-year-old child who is being treated for acute poststreptococcal glomerulonephritis (APSGN), what information should the nurse plan to give the parents? 51.A client has been in a coma for two months and is maintained on bed rest. At what angle should the nurse adjust the head of the bed to prevent the effects of shearing force? 52. A nurse is caring for a client with a diagnosis of renal calculi secondary to hyperparathyroidism. Which type of diet should the nurse explore with the client when providing discharge information? 53. A nurse provides dietary teaching about a low-sodium diet for a client with hypertension. Which nutrient selected by the client indicates an understanding about foods that are low in natural sodium? 54. A 1-day-old infant with an imperforate anus undergoes a pull-through procedure with an anoplasty. What should postoperative nursing care include? 55. A client experiences occasional right upper quadrant pain attributed to dyspepsia. The nurse is providing discharge instructions, including a list of foods that cause dyspepsia. The list should include: 56. A client drank 7.5 oz of orange juice, 6 oz of tea, and 8 oz of eggnog. How many milliliters of fluid were consumed by the client? Record your answer using a whole number. __________ mL 57. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort? 58. A severely dehydrated infant with gastroenteritis is admitted to the pediatric unit. Nothing-by-mouth (NPO) status is prescribed. The parents ask why their baby cannot be fed. The nurse explains that this is necessary to: 59. A nurse is caring for a client who is experiencing urinary incontinence. The client has an involuntary loss of small amounts (25 to 35 mL) of urine from an overdistended bladder. This should be documented in the medical record as: 60. After a laryngectomy is scheduled, the most important factor for the nurse to include in the preoperative teaching plan is: 61. A client has a hiatal hernia. The client is 5 feet 3 inches tall and weighs 140 pounds. When the nurse discusses prevention of esophageal reflux, what should be included? 62. A client suffered an injury to the leg as a result of a fall. X-ray films indicate an intertrochanteric fracture of the femur. The client will be placed in Buck's traction until surgery is performed. When considering the client's plan of care, the nurse recalls that the primary purpose of Buck's traction is to: 63. A nurse is caring for a client with acute kidney failure who is receiving a protein-restricted diet. The client asks why this diet is necessary. What information should the nurse include in a response to the client's questions? 64. An older adult tells the nurse, "I read about a vitamin that may be related to aging because of its effect on the structure of cell walls. I wonder whether it is wise to take it." The nurse concludes the client probably is referring to: 65. A client with a history of a pulmonary embolus is to receive 3 mg of warfarin (Coumadin) daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary? 66. A client who recently experienced a brain attack (CVA) and who has limited mobility complains of constipation. What is most important for the nurse to determine when collecting information about the constipation? 67. A home care nurse is teaching a client of the Orthodox Jewish faith about food supplements that can promote weight gain. Which client statement supports the nurse's conclusion that the teaching is successful? 68. A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity? 69. A back brace is prescribed for a client who had a laminectomy. What instruction should the nurse include in the teaching plan? 70. A nurse teaches a client with calcium-based renal calculi about foods that can be eaten on a low-calcium diet (400 mg/day). The nurse concludes that the teaching was effective when the client selects what food items from the menu? (Select all that apply.) 71. A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish normal bowel pattern? 72. Using the five-digit system, determine the obstetric history in this situation: The client is 38 weeks into her fourth pregnancy. Her third pregnancy, a twin gestation, ended at 32 weeks with a live birth, her second pregnancy ended at 38 weeks with a live birth, and her first pregnancy ended at 18 weeks. 73. The health care provider prescribes a low-fat, 2-gram sodium diet for a client with hypertension. The nurse should explain that the purpose of restricting sodium is to: 74. A client has 4 ounces of apple juice, 6 ounces of tea, and 240 mL of chicken broth. The nurse calculates that the client ingested how many mL of fluid? Record your answer using a whole number. __________ mL 75. A nurse is caring for a client during the transition phase of labor. The nurse determines that the client has entered the second stage of labor when: 76. Which statement by an older adult most strongly supports the nurse's conclusion that the client is impacted with stool? 77. A client has cholelithiasis with possible obstruction of the common bile duct. What should be determined about the client's nutritional status before surgery is scheduled? 78. A client who is to receive radiation therapy for cancer says to the nurse, "My family said I will get a radiation burn." What is the nurse's best response? 79. A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate? 80. A complete blood count (CBC), urinalysis, and x-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. Which is the best reply by the nurse? 81. The nurse caring for a client with a systemic infection is aware that the assessment finding that is most indicative of a systemic infection is: 82. A client is admitted voluntarily to a psychiatric unit. Later, the client develops severe pain in the right lower quadrant and is diagnosed as having acute appendicitis. How should the nurse prepare the client for the appendectomy? 83. A nurse fails to act in a reasonable, prudent manner. Which legal principle is most likely to be applied? 84. A nurse is discussing weight loss with an obese individual with Ménière's disease. Which suggestion by the nurse is most important? 85. The most effective time to teach clients who have sustained a sudden, traumatic, major loss is most often during the acceptance or adaptation stage of coping. The rationale for this fact is that clients in this stage are: 86. A physician orders a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site? 87. Which action by a home care nurse would be considered an act of euthanasia? 88. A nurse who promotes freedom of choice for clients in decision-making best supports which principle? 89. A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? 90. The nurse discovers several palpable elevated masses on a client's arms. Which term most accurately describes the assessment findings? 91. A client has seeds containing radium implanted in the pharyngeal area. What should the nurse include in the client's plan of care? 92. An 85-year-old client is alert and able to participate in care. The nurse understands that, according to Erikson, a person's adjustment to the period of senescence will depend largely on adjustment to which developmental stage? 93. The nurse is caring for a client with a closed soft tissue injury. The nurse describes the injury as a/an: 94. A nurse is teaching a group of parents about child abuse. What definition of assault should the nurse include in the teaching plan? 95. The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? 96. What should the nurse include in dietary teaching for a client with a colostomy? 97. A nurse identifies that an older adult has not achieved the desired outcome from a prescribed proprietary medication. When assessing the situation, the client shares that the medication is too expensive and the prescription was never filled. What is an appropriate nursing response? 98. The nurse is caring for a client that underwent a rhinoplasty surgical procedure 5 hours ago. After administering pain medication, the nurse notes the client is swallowing frequently. The nurse understands that the cause of frequent swallowing is most likely caused from: 99. A postoperative client says to the nurse, "My neighbor—I mean the person in the next room—sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation? 100. A nurse suspects that a client has poison ivy. Assessment findings reveal vesicles on the arms and legs. A vesicle can be described as: 101. The nurse recognizes that what is the reason the faucets on the sinks in a client's room are considered contaminated? 102. The nurse instructs a client with a new colostomy to avoid foods and drinks that produce a large amount of gas, and specifically to avoid the intake of: 103. Which nursing intervention is most appropriate for a client in skeletal traction? 104. What is a nurse's most appropriate response, based on current research, when asked about spanking as a disciplinary technique? 105. A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the nurse should do when caring for this client is to: 106. An 80-year-old female is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated because she is alert and able to care for herself. The nurse's best response is: 107. A nurse anticipates that a hospitalized client will be transferred to a nursing home. When should the nurse begin preparing the client for the transfer? 108. A graduate nurse is preparing to apply to the State Board of Nursing for licensure to practice as a licensed practical nurse. What group primarily is protected under the regulations of the practice of nursing? 109. A client is admitted with a diagnosis of premature labor. The nurse discovers that the client has been using heroin throughout her pregnancy. What is the most appropriate action for the nurse to take? 110. The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? 111. The nurse is providing information about blood pressure to Unlicensed Assistive Personnel (UAP) and recalls that the factor that has the greatest influence on diastolic blood pressure is: 112. When changing the soiled bed linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear? 113. A client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation? 114. Which nursing activities are examples of primary prevention? Select all that apply. 115. A client is admitted to the hospital because of multiple chronic health problems. What is the priority nursing intervention at this time? 116. Health promotion efforts within the health care system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? (Select all that apply.) 117. The nurse recognizes that a common conflict experienced by the older adult is the conflict between: 118. A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive? 119. A nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. On what aspect of care should the nurse focus? 120. A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish ("DNP") order on any information regarding condition or presence in the hospital. What is the best response by the nurse? 121. Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? (Select all that apply.) 122. Nurses care for clients in a variety of age groups. In which age group is the occurrence of chronic illness the greatest? 123. Nurses are held responsible for the commission of a tort. The nurse understands that a tort is: 124. A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit? 125. What should the nurse assess to determine whether a 75-year-old individual is meeting the developmental task associated with aging? 126. Which nursing action is confidential and protected from legal action? 127. An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls the expected sensory losses associated with aging. (Select all that apply.) 128. A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? 129. A newly hired nurse, during orientation, is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. What is the most appropriate nursing response? 130. Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? 131. A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? (Select all that apply.) 132. Which drug requires the nurse to monitor the client for signs of hyperkalemia? 133. A nurse overhears an unlicensed assistive personnel (UAP) talking with a client about the client's marital and family problems. The nurse identifies that the UAP is providing false reassurance when the UAP states: 134. A client with a leg prosthesis and a history of syncopal episodes is being admitted to the hospital. When formulating the plan of care for this client, the nurse should include that the client is at risk for: 135. A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client: 136. What nursing actions best promote communication when obtaining a nursing history? (Select all that apply.) 137. A hospital has threatened to refuse the discharge of a newborn until the parents pay part of the hospital bill. The nurse is aware that the legal term that best describes this situation is: 138. A client using fentanyl (Duragesic) transdermal patches for pain management in late-stage cancer dies. What should the hospice nurse who is caring for this client do about the patch? 139. A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures to: 140. A client is diagnosed with AIDS. When examining the client's oral cavity, the nurse assesses white patchy plaques on the mucosa. The nurse recognizes that this finding most likely represents what opportunistic infection? 141. While instructing a community group regarding risk factors for coronary artery disease, the nurse provides a list of risk factors that cannot be modified. What should be included on the list? 142. The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)?