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Hesi Exit Exam with Answers latest
update(2022)
A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of the solution for eight hours, how many ml of full strength feeding will the nurse need? (Enter numeric value only.) - ANSWER 200ml. 25 ml of full strength feeding mixed with 25ml of water provided 50ml of half strength. 25ml × 8 hours= 200ml An elderly male client is experiencing urinary incontinence. What is the best initial nursing action? - ANSWER Apply an external condom catheter
- 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? - ANSWER Reschedule administration of the antibiotic until after he completes his prayers UAP using a hand sanitzers that is alcohol for 2 minutes - ANSWER tell that hand sanitizer use is less > 2min 5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a scheduled procedure. The child weighs 44 pounds. How many mg of the medication should the nurse administer - ANSWER Answer: 800 Rationale: First, convert the child's weight to kg: 44 pounds divided by 2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg = 800mg
- 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? - ANSWER Compare current vital signs with previous vital signs 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? - ANSWER Have the parent take the child for emergency help 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? - ANSWER Postpartum psychosis
The nurse identifies a priority diagnosis of, "Altered comfort related to menstrual cramps" for a 25-year-old female client. Which self-care activity should the nurse emphasize in the client's teaching plan? - ANSWER Regular aerobic exercise. Psych/Alcohol/Tylenol overdose antidote - ANSWER Give Mucomyst Medical Surgical/Laxative abuses - ANSWER Patient -taking Milk of Magnesium Spiritual/Documentation - ANSWER Native American - Allow pt's family to stay in the room Leadership- Interpreter informed consent - ANSWER Pt should sign the consent Geriatrics/Emergency Rib fractures fall - ANSWER Pulmonary embolism A client diagnosed with major depression is being allowed a weekend pass from the psychiatric unit. Which instruction should the nurse provide to the client's family? - ANSWER Involve the client in usual at home activities Upon assessment, the nurse discovers that a postpartum client has persistent red lochia. Which of the following does this assessment finding suggest to the nurse? - ANSWER Coagulation disorders The healthcare provider performs peritoneal dialysis on a client, after which 2 liters of fluid is drained. What action should the nurse complete first? - ANSWER Assess vital signs. After administering a medication through a nasogastric tube connected to suction, what action should the nurse take first? - ANSWER Clamp the tube The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.; Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell count of 15,000. What should the nurse implement? - ANSWER Determine if Client B has two units of packed cells available in the blood bank. Triage question with a train wreck 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 or priority with the top item requiring the most immediate care and the bottom item requiring the least priority care) - ANSWER A mother and father have just arrived on the.
A nurse working on a mental health unit where a diagnosis of bulimia nervosa is being admitted. Which of the following symptoms would the nurse most likely NOT expect to find with this client? - ANSWER severe over-or under-weight The charge nurse is developing the nursing guidelines for a coronary care unit. Which references is likely to be the most useful in developing these guidelines? - ANSWER The Scope of Standards of Practice from the American Nurses Association Which assessment finding indicates a client's readiness to leave the nursing unit for a Bronchoscopy? - ANSWER On-call sedation administered. A nurse-manager is preparing an annual budget for the unit. Nursing salaries should be included in which component of the budget? - ANSWER Operating budget The nurse has not finished administering routine oral medication because on e 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? - ANSWER UAP feed the two clients, PN finish oral medications and RN monitor clients with chest pain and rectal bleeding What is manntiol drug used for? - ANSWER To promote diuresis in prevention and treatment of oliguric phase of renal failure, ICP, IOP, edema in CHF. 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? - ANSWER Edema A 40-year-old client with type 1 diabetes developed chronic kidney (CKD) disease 6 months ago. Because of secondary complications often associated with this illness the nurse plans to carefully assess for signs of what condition? - ANSWER Anemia A pt on a trachea/endotrach with gurgling sound - ANSWER always pick suctioning Know how the chest tube vac machine works - there is a picture of a chest tube vac machine. - ANSWER this q is very easy just mark the spot on the tube for the amount of 125 ml of drainage Child w/ hemophila - ANSWER have parent pad the corners of the furniture due to bleeding. You are preparing a plan of care for a client who is a Jehovah's Witness.The client has been told that surgery is necessary. With consideration to the client's religious preferences in development of the plan of care, you would document what? - ANSWER The administration of blood and blood products is forbidden
A client is admitted with a diagnosis of acute renal failure. The nurse should monitor closely for what? - ANSWER Drug toxicity A 68-year-old male has been admitted to the hospital with abdominal pain, anemia and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. - ANSWER The nurse should help him onto the bedpan/with the urinal Nurse writes on the chart of Bob Miller that his nurse, Nurse Smith did not take great care of Mr. Miller. Nurse Jones has committed which of the following? - ANSWER Libel A client is prescribed Zolpidem (Ambien). Which of the following side effects should be monitored while the client is taking this medication? - ANSWER Daytime drowsiness Translator is working with the nurse who is giving discharge instructions to a non- English 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? - ANSWER Ask the translator if there is a reason for the lengthiness of the translation Who is at risk for rib fracture - ANSWER Elderly pt. Splint - ANSWER Chest compression or chest splint after surgery - they used it for comfort Metabolic syndrome - high cholesterol & - ANSWER high cholesterol & high BP (cardiac strip) Know how to prevent SIDS death - ANSWER Instruct parents to have a firm mattress and avoid laying infant in prone position. Hypertension Diet Teaching- presented with a list of menu choices, the best choice was
- ANSWER Baked pork chops, applesauce,etc Teenager attempted suicide and during group session became upset and left group - ANSWER Go to client room and ask what happened. Client has rapid speech, flight of ideas, 3hrs of sleep - ANSWER client experiencing high levels Depakote New RN to Unit - ANSWER best client to assign is client 4 days post MI Incorrect Delegation - ANSWER LVN/LPN to remove staples from abdominal wound While the nurse is inserting a nasogastric tube, the client becomes cyanotic. What intervention should the nurse implement? - ANSWER Withdraw the nasogastric tube
Magnesium - ANSWER Alcohol pt (Magnesium 1.5 to 2.5) Endotrach has slipped into right main bronchus of no breath sounds are heard (Audio/Visual) - ANSWER Pleaurvac, know how to set vac at 850 Chron's disease - ANSWER decrease intestinal activity Dialysis - ANSWER educate client of the reality of condition Acute Pancreatitis - ANSWER withhold food and fluid intake 39 to 48 Glucose - ANSWER Notify healthcare provider of client's status Ankle brachial index - ANSWER ensure that you provide meticulous foot care to client Anterior Cruciate Ligament injury - ANSWER crutches Select all that apply) Mantoux test - ANSWER select all except 45-degree angle Late decelerations - ANSWER nurse should turn off the Pitocin infusion first Crohn's Disease - Which has lowest Na+- choose - ANSWER Horseradish (choices are ketchup, steak sauce, pickle relish, horseradish) Disseminated intravascular coagulation (DIC) - ANSWER best test to diagnose, D- Dimer Septic shock-best class of medicine to give are - ANSWER Anti infectives Adolescents and drug abuse at 13yrs old- - ANSWER mostly likely to use, Paint thinners A female client who has been taking the corticosteroid methylprenisolone (Solu-Medrol) for three weeks reports to the nurse that she has gained ten pounds since starting the medication, and she wants to stop taking it. What is the best response by the nurse? - ANSWER The medication must be disconnected gradually, tapering the dose each day. In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse? - ANSWER An elderly client with Alzheimer's disease complicated by dysphagia. 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? - ANSWER Have the parent take the child for emergency help
A nurse who is new to the pediatric unit is positioning a 6 month-old for an injection of penicillin V (Pen V) in the dorsogluteal muscle. Which action should the nurse-manager who is supervising this nurse take first? - ANSWER Instruct the nurse to select another injection site. After diagnosis and initial treatment of a 3-year-old child 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 function? - ANSWER "Cough suppressants can be used four times a day." 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? - ANSWER Postpartum psychosis The nurse is caring for a client who was admitted two hours ago with confusion, Kussmaul respirations, and warm, flushed skin. The healthcare provider determines the client is in acute renal failure (ARF). Which intervention is most important for the nurse to include in this clients plan of care? - ANSWER Hourly neurological assessments. The nurse observes a 2cm area of non-blanchable erythema on the sacrum of an immobile client. What documentation of this finding is best for the nurse to enter into the client's record? - ANSWER Stage 1 pressure ulcer on sacrum. A client diagnosed with major depression is being allowed a weekend pass from the psychiatric unit. Which instruction should the nurse provide to the client's family? - ANSWER Involve the client in usual at home activities A 14-year-old male client arrives at the emergency room in status epilepticus. He was diagnosed with a seizure disorder in childhood. What is the most likely cause of his present condition? - ANSWER Acute withdrawal from anticonvulsant medication. 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 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 During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir (Zovirax) prior to this pregnancy tells the nurse that she is experiencing an episode of genital herpes. Which nursing intervention has the highest priority? -
tie. What action should the nurse implement? - ANSWER Reposition the restraints ties, securing them to the bed frame After administering the first dose of newly prescribed medications to four clients within a thirty minute time frame, the nurse evaluates each client for therapeutic responses or any adverse reactions. Which medication should the nurse evaluate first? - ANSWER Hydromorphone (Dilaudid) What is the most important symptom the nurse should monitor the client for while assisting with the insertion of a subclavian central venous catheter? - ANSWER Shortness of breath. A client admitted to the hospital is suspected of having meningitis. The nurse should plan to prepare the client for which diagnostic test? - ANSWER Lumbar puncture 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? - ANSWER Supervision of the renovation of an old house the family just purchased due to teratogen defect. The nurse notes that a postoperative adult client's respiratory rate is 10 breaths/minute. Which factor in the client's history is the most likely explanation for this finding? - ANSWER The PCA pump containing morphine sulfate was discontinued 15 minutes before vital signs were taken. 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? - ANSWER Hypothermia, decreased cardiac output, and decreased respiratory functioning While the nurse is inserting a nasogastric tube, the client becomes cyanotic. What intervention should the nurse implement? - ANSWER Withdraw the nasogastric tube Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mother's vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. What action should the nurse take first? - ANSWER Perform fundal massage until firm The nurse-manager of a perinatal units 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? - ANSWER A 35-year- old with lupus erythematosus 121. Who is at risk for rib fracture - Elderly pt. 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? - ANSWER Hypothermia, decreased cardiac output, and decreased respiratory functioning A client is receiving a continuous infusion of normal saline at 125ml per hour. The nurse prepares to change the primary IV tubing and hang a new bag of normal saline to maintain the prescription. In which sequence should the nurse implement the procedure? - ANSWER (Arrange with first on top and last on bottom.) Spike a new bag- open the clamp-close the clamp-place the pumpattach the distal end-open all tubing clamps A client who is wheelchair-bound demonstrates a positive Thomas test after admission to the rehabilitation unit. The health care provider prescribes positioning the client prone for 30minutes three times each day to prevent further contractures. Based on this finding, what change in the client's plan of care should the nurse expect? - ANSWER There may be a delay in the rehabilitation process. While the nurse is inserting a nasogastric tube, the client becomes cyanotic. What intervention should the nurse implement? - ANSWER Withdraw the nasogastric tube A client with a general anxiety disorder is pacing the hallway. The client tells the nurse, "My heart is just racing and sometimes it feels like it's fluttering. I'm feeling short of breath and dizzy." What action should the nurse implement first? - ANSWER Obtain the clients vital signs.
. Translator is working with the nurse who is giving discharge instructions to a non- English 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? - ANSWER Ask the translator if there is a reason for the lengthiness of the translation An Elderly man is having trouble urinating and unsteady he uses a wheelchair to walk to the bathroom what should the nurse implement? - ANSWER provide a raised toilet seat 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? - ANSWER Difficulty visualizing objects at a distance also known as myopia. Client has a Lithium Rx level of 0.54 (know Lithium ranges - ANSWER Low, so the answer is to ask client if they have been taking their medication everyday (Select all that apply) Determining pain level for 3mo old infant - ANSWER infant will clinch fists, increase pulse, restlessness, increased respiratory effort 5yr old burn victim has pot of hot liquid fall on him, what should nurse tell mother to do first- - ANSWER nurse should tell mother to remove clothing and place in cool bath
which quadrant should the nurse place the external fetal heart transducer? - ANSWER (Click the chosen location. To change, click on the new location.) 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? - ANSWER Reduce cerebral edema and lower intracranial pressure. The nurse is preparing a discharge plan for an older client who was recently diagnosed with Alzheimer's disease. Which intervention should the nurse suggest to the spouse if the client becomes uncooperative at home? - ANSWER Ensure a calm and predictable environment. A mother brings her 15-month old son and 6 year-old daughter to the clinic for immunizations. Both children are fretful and obviously have upper respiratory infections. The mother tells the nurse that the younger child ran a fever of 100.2oF following his last immunization. What plan is best for the nurse to implement? - ANSWER Administer the boosters and instruct the mother to call the clinic if either child's temperature exceeds 101oF. Pregnancy Induced Hypertension - ANSWER high blood pressure, blurred vision, headache, Proteinuria, Abdominal pain A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium (Cs) loaded in a vaginal applicator. What action should the nurse implement? - ANSWER Wear a dosimeter film badge when in the client's room A client who has localized eczematous eruptions on both hands is diagnosed as having contact dermatitis. What instructions should the nurse include on the clients discharge teaching plan? - ANSWER Take prescribed antihistamine near bedtime. The community health nurse is attempting to address the issue of child abuse in a large metropolitan area. A primary prevention program for child abuse might include which program? - ANSWER High school child development and parenting classes. Risk management: pt fell while using some equipment... charge nurse trying to find out what happened- how? - ANSWER hospital polices A client has a history of chronic atrial fibrillation. Which instruction should the nurse include in the teaching plan for this client? - ANSWER Be sure to take the prescribed daily aspirin. Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mother's vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. What action should the nurse take first? - ANSWER Perform fundal massage until firm
It is most important for the nurse to use an IV pump and/or Buretrol, an in-line volumecontrol device, when initiating IV therapy for a client following which surgical procedure?. - ANSWER Craniotomy
. Which strategy is most important for the nurse to use when assisting a client with myasthenia gravis to devise a daily routine? - ANSWER Female with a head injury whose pupils are fixed and dilated. A male infant born at 30-weeks gestation at an outlying hospital is being prepared for transport to a level IV neonatal facility. His respirations are 90/min, and his heart rate is 150 beats per min. Which drug is the transport team most likely to administer to the infant? - ANSWER Beractant (SURVANTA) 100mg/kg per endotracheal tube. A 60 year-old female client takes NPH insulin each morning. What would necessitate holding this clients usual morning NPH insulin dose? - ANSWER The client is NPO for surgical debridement of a leg ulcer at 11.00am. Which finding should the nurse expect a client to exhibit who is newly diagnosed with fibromyalgia? - ANSWER Disrupt in sleep patherns. Chest tube disconnect - ANSWER ( Put the end of the tube in a sterile bottle fill with Normal saline and connect back to patient)
