EXIT HESI EXAM 2022/2023

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A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider? a. WBC count 8,000 b. platelets 150,00... 0 c. aspartate aminotransferase 10 units d. erythrocyte sedimentation rate 75mm A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests? a. platelet count b. potassium level c. creatine clearance d. prealbumin A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first? a. place an ice pack over the cast b. palpate the pulse distal to the cast c. teach the client to keep the cast clean and dry d. position the casted extremity on a pillow A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? SATA a. keep objects in the clients room in the same place. b. ensure there is high-wattage lighting in the clients room. c. approach the client from the side d. allow extra time for the client to perform tasks e. touch the client gently to announce presence A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the nurse should identify that which of the following electronic database has the most comprehensive collection nursing articles? a. medline b. C inahl c. ProQuest d. health source A nurse in the emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a brain injury. Which of the following actions should the nurse take first? a. obtain a baseline EKG b. Obtain a blood specimen for ABG analysis c. insert an 18 gauge IV catheter d. Administer 100% humidified oxygen A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? a. Place food on the left side of the client's mouth when he is ready to eat. b. Provide total care in performing the client's ADLs. c. Maintain the client on bed rest. d. Place the client's left arm on a pillow while he is sitting. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take? a. Confront the client about this behavior. b. Express sympathy for the client's situation. c. Speak assertively to the client. d. Stand within 30 cm (1 ft) of the client when speaking with them. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take? a. Cleanse equipment before removal from the client's room. b. Limit the client's visitors to 30 min per day. c. Discard the client's linens in a double bag. d. Discard the radioactive source in a biohazard bag A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take? a. Position the client supine b. Prepare an IV bolus of dextrose 5% in water c. Administer methylergonovine IM d. Administer calcium gluconate IV A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? a. Experiencing delusions b. Male gender c. Pervious violent behavior d. A history of being in prison A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? a. Place the cap from the solution sterile side up on clean surface b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body's first c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm (1-inch) border around any sterile drape or wrap that is considered contaminated. d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level; should be ABOVE waist level A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? a. Eat a light snack before bedtime c. Stay in bed at least 1 hr if unable to fall asleep d. Take a 1 hr nap during the day e. Perform exercises prior to bedtime A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first? a. Educate the client about current medical diagnosis b. Refer the client to a meal delivery program c. Identify environmental hazards in the home d. Arrange for client transportation to follow-up appointments Rationale Priority: Assess first. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client? a. "Can you tell me who visited you today?" b. "What high school did you graduate from c. "Can you list your current medications?" d. "What did you have for breakfast yesterday?" A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. > b. Blood glucose level greater than 200 mg/dL at bedtime c. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC d. HbA1c level less than 7% A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination? a. The client is experiencing an adverse reaction to rifampin b. The client's seizure disorder is no longer under control c. The client is showing evidence of phenytoin toxicity d. The client is having adverse effects due to combination antimicrobial therapy A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse? a. Increase in frequency of swallowing→ may indicate bleeding b. Moderate sanguineous drainage on the drip pad c. Bruising to the face→ side effect d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative) - Rationale "Requires immediate action" choose the worst possibility that could lead to. ABC A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? a. Give scheduled doses of acetaminophen every 6 hr b. Monitor the child's cardiac status c. Administer antibiotics via intermittent IV bolus for 24 hr d. Provide stimulation with children of the same age in the playroom A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco? a. Use of tobacco might lead to alcohol and drug abuse b. Smoking in adolescence increases the risk of developing lung cancer later in life c. Use of tobacco decreases the level of athletic ability d. Smoking in adolescence increases the risk of lifelong addiction A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? a. Total bilirubin b. Urine ketones c. Serum potassium- diuretic that retains potassium= hyperkalemic risk d. Platelet count A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role? a. "I will let the client know that I am available as the interpreter." b. "I will receive a small fee for interpreting for this client." c. "I am glad I'm available today, but when I'm not, you can use a family member." d. "I will let the client know that an interpreter is unavailable during the night shift." A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year- old. Which of the following actions should the nurse take? a. Tell the child they will feel discomfort during the catheter insertion. b. Use a mummy restraint to hold the child during the catheter insertion. c. Require the parents to leave the room during the procedure. A nurse is caring for a client who has arteriovenous fistula which of the following findings should the nurse report? a. Thrill upon palpation. b. Absence of a bruit. c. Distended blood vessels d. Swishing sound upon auscultation A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching? a. "I will soak in the tub rather and showering" b. "I will wear loose clothing around my ICD" c. "I will stop using my microwave oven at home because of my ICD" d. "I can hold my cellphone on the same side of my body as the ICD" A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make? a. "Describe your feelings to me about being pregnant" b. "You should discuss your feelings about being pregnant with your provider" c. "Have you discussed these feelings with your partner?" d. "When did you start having these feelings?" A nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care? a. Encourage a maximum fluid intake of 1,500 ml per day. b. Increase the amount of refined grains in the client's diet. c. Provide the client with a cold drink prior to defecation. d. Administer a rectal suppository 30 minutes prior to scheduled defecation times. A nurse is performing physical therapy for a client who has Parkinson's disease. Which of the following statements by the client indicates the need for a referral to physical therapy? a. "I have been experiencing more tremors in my left arm than before" b. "I noticed that I am having a harder time holding on to my toothbrush" c. " Lately, I feel like my feet are freezing up, as they are stuck to the ground" d. "Sometimes, I feel I am making a chewing motion when I'm not eating" A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect? a. Increased creatine. b. Increased hemoglobin. c. Increased bicarbonate. d. Increased calcium. A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take? a. "Did the doctor discuss with you that there was a change in this medication?" b. "I recommend that you take this medication as prescribed" c. "Do you know why this medication is being prescribed to you?" d. " I will call the pharmacist now to check on this medication" A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge? a. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg. b. A 15-year-old client who delivered via emergency cesarean birth 1 day ago. c. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage. d. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration. A nurse in a provider's office is reviewing the laboratory results of a group of clients. Which to report? a. Herpes simplex. b. Human papillomavirus c. Candidiasis d. Chlamydia A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian a. A client who has a prescription for warfarin and states "I will need to limit how much spinach I eat". b. A client who has gout and states, "I can continue to eat anchovies on my pizza." c. A client who has a prescription for spironolactone and states "I will reduce my intake of foods that contain potassium". d. A client who has states "I'll plan to take my calcium carbonate with a full glass of water". A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? a. Place the tip of the thermometer under the center of the infant's axilla. b. Pull the pinna of the infant's ear forward before inserting the probe. c. Insert the probe 3.8 cm (1.5in) into the infant's rectum. d. Insert the thermometer in front of the infant's tongue. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information should the nurse include? a. Children who have varicella are contagious until vesicles are crusted. b. Children who have varicella should receive the herpes zoster vaccination. c. Children who have varicella should be placed in droplet precaution. d. Children who have varicella are contagious 4 days before the first vesicle eruption. A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? a. Withhold the next dose. b. Increase the dosage. c. Discontinue the medication. d. Administer the medication. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? a. Pregabalin b. Lorazepam c. Colchicin d. Codeine. A nurse is caring who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? a. Prime IV tubing with 0.9% sodium chloride. b. use a 24- gauge IV catheter c. obtain filter less IV tubing d. place blood in the warmer for 1 hr A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? a. Looking at alphabet flashcards. b. Playing with a large plastic truck. c. Use scissors cut out paper shapes. d. Watching a cartoon in the dayroom. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? a. Coffee with creamer. b. Lettuce with sliced avocados. c. Broiled skinless chicken breast with brown rice. d. Warm toast with margarine. A nurse is caring for a client who is in active labor and requests pain management. Which of the following actions should the nurse take? a. Administer ondansetron. b. Place the client in a warm shower. c. Apply fundal pressure during contractions. d. Assist the client to a supine position. A nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? a. Below-the knee amputation b. Fractured tibia c. 95% full-thickness body burn d. 10cm (4in) laceration to the forearm A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? a. Remove the client's restraint every 4hr b. Document the client's condition every 15 min c. Attach the restrain to the bed's side rails d. Request a PRN restrain prescription for clients who are aggressive A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader? a. Acts as an advocate for the nursing unit. c. Priorities staff request over client needs. d. Provides routine client care and documentation. A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports that she has been following her care. The nurse should identify which of the following findings indicates a need to revise the client's plan of care. a. Serum sodium 144 mEq/ b. Hba1c 10 % c. Random serum glucose 190 mg/dl. A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate? a. You may breastfeed unless your nipples are cracked or bleeding b. You must use a breast pump to provide breast milk. c. You must use nipple shield when breastfeeding. d. You may breastfeed after your baby develops his antibiotics. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information? Exhibit. a. loss of consciousness. (priority)- decreased LOC can mean less o2 going to the brain. b. Skin turgor c. deep tendon reflexes d. Bowel sounds A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take? a. Submerge the adolescent feet in ice water b. Cover the adolescent with a thermal blanket → if hypothermia. c. Administer oral acetaminophen d. Initiate seizure precautions A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include? a. Document the client's conditions every 15 minutes b. Attach the restraints to the beds side rails c. Request a PRN restraints prescription for clients who are aggressive d. Remove the client restraints every 4 hours A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention? a. Providing pain management b. Offering emotional support c. Preventing infection d. Initiating IV fluid resuscitation- they are at risk for hypovolemic shock d/t 3rd spacing A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about dying." which of the following responses by the nurse is appropriate? (SATA) A. Hospice will take good care of your mom, so I wouldn't worry about that. b. Let's talk about you mom's cancer and how things will progress from here. D. Tell her not to worry. She still has plenty of time left. e. You sound like you have questions about your mom dying. Lets talk about it. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care? a. A client who is taking bumetanide and has potassium level of 3.6 mEq/L (normal) b. A client who is scheduled for colonoscopy and taking sodium phosphate c. A client who received a Mantoux test 48 hrs ago and has induration d. A client who is taking warfarin and has INR of 1.8 (normal if taking warfarin) A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? a. Clarify the source of the referral. b. Implement the nursing process c. Schedule a time for the home visit d. Contact the family by phone A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make? a. You have the right to decide who receives information b. Your partner can be a great source of support for you at this time c. Is there a reason you don't want your partner to know about your procedure? d. The provider will be tactful when talking to your partner A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 9o.7 (200 lb). The nurse should identify the weight of the following total percentage? a. 7.5% b. 15% c. 8.1% d. 13.3% A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? a. Perform fundal massage (massage if fundus is boggy) b. Pour water from a squeeze bottle over the patients perineal area. c. Insert an indwelling urinary catheter. d. Apply cold therapy to the client's perineal area.( warm) A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching? a. Avoid hot tub while wearing the patch b. Apply patch to your forearm c. Avoid high-fiber foods while taking this medication d. Remove the patch for 8 hours every day to reduce the risk for tolerance. A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? a. We should discuss resources to implement in your daily life b. Let me show you simple relaxation exercises to manage stress. c. Let's talk about how you can change your response to stress d. We should establish our roles in the initial session. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? a. Avocados b. Whole grain bread c. Pepperoni pizza d. Smoked salmon A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse report? - Lower platelets A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include? A. Use the client's children to provide interpretation. B. The nurse was going to do the interpretation C. Offer client's translation services for a nominal fee. D. Evaluate the clients' understanding at regular intervals A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make? a. "I can give you information about respite care if you are interested." b. "You should consider taking a sleeping pill before bed each night" c. "It must be difficult taking care of someone who is terminally ill" d, "You are doing a great job taking care of your mother" A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child's glucose. The nurse should identify this finding as an adverse effect of which of the following medications a. Methylprednisolone. b. Ondansetron. c. Guaifenesin. d. Amoxicillin The nurse is providing teaching about folic acid to a client who is prima gravida. Which of the following information should the nurse include in the teaching? a. "You should take folic acid to decrease the risk of transmitting infections to your baby" b. "You should consume a maximum of 300 micrograms of folic acid every day". c. "You can increase your dietary intake of folic acid by eating cereals and citrus fruits". d. "You can expect your urine to appear red-tingled while taking folic acid supplements". A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority? a. Social relationship with peers. b. Plans for attending school while pregnant. c. Medicaid? d. Understanding of infant care. A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include? a. Critical pathways have unlimited timeframe for completion b. Decrease health care costs. c. Critical pathway if variances D. Used to create the critical pathway. A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following should the nurse report to the provider? Exhibit 1 Blood pressure: 102/56 mm Hg. Heart rate: 95/min Respiratory rate: 18/min Temperature: 37.4C (99.3F) Exhibit 2 Medication Administration Record Clozapine 150 mg PO twice daily Benztropine 0.5 mg PO twice daily as needed for tremors. Exhibit 3 Nurse's notes: Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in the past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of breakfast and reports slightly nauseous. a. Dietary intake b. Heart rate. c. Sore throat. d. Blood pressure. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel a. "The nurse is legally responsible for the actions of the AP". b. "An AP can perform tasks outside of his range if he has been trained". c. "An experienced AP can delegate to another AP". d. "An RN evaluates the client needs to determine tasks to delegate" A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? A. Contractions lasting 80 seconds B. FHR baseline 170/min C. Early decelerations in the FHR D. Temperature 37.4C (99.3 A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia the following actions is the nurse's priority? a. Consult with a case manager about insurance coverage. b. Counsel caregivers about respite care options. c. Ensure that the client has a referral for physical therapy. d. Refer the client to a local stroke support group. A nurse in a mental health unit is planning room assignments for four clients. Which of the following client should be closest to the nurse's station? a. A client who has an anxiety disorder and is experiencing moderate anxiety. b. A client who has somatic symptom disorder and reports chronic pain. c. A client who has depressive disorder and reports feeling hopeless. d. A client who has bipolar disorder and impaired social interactions. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? a. Encourage the client to spend time in the day room b. Withdraw the client's TV privileges is the does not attend group therapy c. Encourage the client to take frequent rest periods d. Place the cline in seclusion when he exhibits signs of anxiety A nurse is admitting medications to a group of clients. Which of the following occurrences requires the completion of an incident report? a. A client receives his antibiotics 2hr late b. A client vomits within 20min of taking his morning medications c. A client requests his statin to be administered at 2100 d. A client asks for pain medication 1hr early A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her newborns. The client asks the nurse to warm up seaweed soup that the client's partner brought for her. Which of the following responses should the nurse make? a. "Does the doctor know you are eating that?" b. "Why are you eating seaweed soup?" c. "Of course I will heat that up for you" d. "The hospita [Show More]

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