2020 HESI EXIT RN EXAM V1-V7 110 OUT OF THE 160 TOTAL QUESTIONS FOR EACH
1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink
• Review with the client the need to avoid foods that are rich in milk and cream
• Stroke secondary to hemorrhage
3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client
who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side
rails. What action should the nurse implement?
days. Which assessment finding requires immediate follow-up?
• Describes life without purpose
What information should the nurse include in the client’s teaching plan?
• Further evaluation involving surgery may be needed
6. A client who recently underwear a tracheostomy is being prepared for discharge to home. Which
instructions is most important for the nurse to include in the discharge plan?
• Teach tracheal suctioning techniques
7. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen
reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14
breaths / minute. What action should the nurse implement?
• Document the assessment data
8. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client
alarm should the nurse investigate firs?
• Respiratory apnea of 30 seconds
• Check the client for lacerations or fractures
• Inform the anesthesia care provider
determine if an S3 heart sound is present, what action should the nurse take first?
• Listen with the bell at the same location
12. A 66-year-old woman is retiring and will no longer have a health insurance through her place of
employment. Which agency should the client be referred to by the employee health nurse for health
should the nurse instruct the client to take with the tetracycline?
• Toasted wheat bread and jelly
14. Following a lumbar puncture, a client voices several complaints. What complaint indicated to the
nurse that the client is experiencing a complication?
• “I have a headache that gets worse when I sit up”
• “I am having pain in my lower back when I move my legs”
• “My throat hurts when I swallow”
• “I feel sick to my stomach and am going to throw up”
15. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with
incontinence. Which action should the nurse implement?
• Obtain a clean catch mid-stream specimen
keeping with the child’s dietary restrictions. Which foods are contraindicated for this child?
• Foods sweetened with aspartame
should the circulating nurse provide?
• Direct the nurse to continue the surgical hand scrub for a 5 minute duration
• Bagel with jelly and skim milk
optimal number of registered nurses will be working that shift. In planning assignments, which
client should receive the most care hours by a registered nurse (RN)?
office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom
of the child’s foot. Which action should the nurse implement first?
• Cleanse the foot with soap and water and apply an antibiotic ointment
• Provide teaching about the need for a tetanus booster within the next 72 hours.
• have the mother check the child's temperature q4h for the next 24 hours
• transfer the child to the emergency department to receive a gamma globulin injection
21. The mother of an adolescent tells the clinic nurse, “My son has athlete’s foot, I have been
applying triple antibiotic ointment for two days, but there has been no improvement.” What
instruction should the nurse provide?
Stop using the ointment and encourage complete drying of the feet and wearing clean socks.
22. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and
levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the
prescribed dosage is too high for this client? The client experiences
• Bradycardia and constipation
• Lethargy and lack of appetite
• Muscle cramping and dry, flushed skin
• Palpitations and shortness of breath
and palpitations. Which finding is most important for the nurse to assess to the client?
• Obtain a list of medications taken for cardiac history
at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter
• Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml =
• Fluid shifts from intravascular to interstitial area due to decreased serum protein
• Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
• Increased circulating aldosterone levels that increase sodium and water retention
this sound? (Please listen to the audio first to select the option that applies)
• Rationale: A murmur is auscultated as a swishing sound that is associated with the blood
turbulence created by the heart or valvular defect.
500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100
mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If
rounding is required, round to the nearest tenth)
Rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml
28. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six
hours for four days. What assessment is most important for the nurse to complete?
• Auscultate the client's bowel sounds
• Observe for edema around the ankles
• Measure the client’s capillary glucose level
• Count the apical and radial pulses simultaneously
Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes
constipation, so it is most important to Auscultate the client's bowel sounds
breathing, and she asks the nurse to document this in her medical record. What action should the
• Ask the client to discuss “do not resuscitate” with her healthcare provider
• Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour
31. A female client reports that her hair is becoming coarse and breaking off, that the
outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which
follow-up question is best for the nurse to ask?
• Have you noticed any changes in your fingernails?
Rationale: The pattern of reported manifestations is suggestive of hypothyroidism
32. After a third hospitalization 6 months ago, a client is admitted to the hospital with
up blood. What assessment finding warrants immediate intervention by the nurse?
• Capillary refill of 8 seconds
• The client voluntarily grants permission for the procedure to be done
• The client is competent to sign the consent without impairment of judgment
• The client understands the risks and benefits associated with the procedure
34. Following surgery, a male client with antisocial personality disorder frequently requests
should the charge nurse implement?
• Advise the client that assignments are not based on clients requests
• Place the implant in a lead container using long-handled forceps
36. The client with which type of wound is most likely to need immediate intervention by the
often irregular and jagged. A laceration wound is often contaminated with bacteria and debris from
whatever object caused the cut.
37. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which
intervention has the highest priority for inclusion in this client’s plan of care?
• Monitor blood pressure frequently
Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate
life-threatening hypertension. The tumor is malignant in 10% of cases but may be cured
completely by surgical removal. Although pheochromocytoma has classically been associated
with 3 syndromes—von Hippel-Lindau (VHL) syndrome, multiple endocrine neoplasia type 2
(MEN 2), and neurofibromatosis type 1 (NF1)—there are now 10 genes that have been identified
as sites of mutations leading to pheochromocytoma.
head of the bed 30 degrees. What is the reason for this intervention?
• To reduce abdominal pressure on the diaphragm
• to promote retraction of the intercostal accessory muscle of respiration
• to promote bronchodilation and effective airway clearance
• to decrease pressure on the medullary center which stimulates breathing
decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing.
39. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the
gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal
muscle. What is the most likely explanation for failure to locate the gallbladder by palpation?
• Palpating in the wrong abdominal quadrant
• Deeper palpation technique is needed
Rationale: a normal healthy gallbladder is not palpable
stopped taking her antianxiety medications, but thinks she may need to start taking them again
because of her increased anxiety. What response is best for the nurse to provide this woman?
• Describe the transmission of drugs to the infant through breast milk
• Encourage her to use stress relieving alternatives, such as deep breathing exercises
• Explain that anxiety is a normal response for the mother of a 3-week-old.
• Inform her that some antianxiety medications are safe to take while breastfeeding
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