2020/2021 HESI EXIT

V2 EXAM 160

C0RRECTLY ANSWERED

QUESTIONS

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1. The nurse knows that which statement by the mother indicates that the mother

understands safety precautions with her four month-old infant and her 4 year-old child?

A) "I strap the infant car seat on the front seat to face backwards."

B) "I place my infant in the middle of the living room floor on a blanket to play with my

4 year old while I make supper in the kitchen."

C) "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air

while the four year old naps on the sofa."

D) "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen

while I make supper."

The correct answer is D: "I have the four year-old hold and help feed the four month-old

a bottle in the kitchen

2. Upon completing the admission documents, the nurse learns that the 87 year-old client

does not have an advance directive. What action should the nurse take?

A) Record the information on the chart

B) Give information about advance directives

C) Assume that this client wishes a full code

D) Refer this issue to the unit secretary

The correct answer is B: Give information about advance directives

3. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after

the immunization was given, the client complains of itchy and watery eyes, increased

anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of

care for this client will be to

A) Maintain the airway

B) Administer epinephrine 1:1000 as ordered

C) Monitor for hypotension with shock

D) Administer diphenhydramine as ordered

The correct answer is B: Administer epinephrine 1:1000 as ordered .

4. Which of these children at the site of a disaster at a child day care center would the

triage nurse put in the "treat last" category?

A) An infant with intermittent bulging anterior fontanel between crying episodes

B) A toddler with severe deep abrasions over 98% of the body

C) A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture

D) A school-age child with singed eyebrows and hair on the arms

The correct answer is B: A toddler with severe deep abrasions over 98% of the body .

5. When admitting a client to an acute care facility, an identification bracelet is sent up

with the admission form. In the event these do not match, the nurse’s best action is to

A) Change whichever item is incorrect to the correct information

B) Use the bracelet and admission form until a replacement is supplied

C) Notify the admissions office and wait to apply the bracelet

D) Make a corrected identification bracelet for the client

The correct answer is C: notify the admissions office and wait to apply the bracelet

6. The nurse is having difficulty reading the health care provider's written order that was

written right before the shift change. What action should be taken?

A) Leave the order for the oncoming staff to follow-up

B) Contact the charge nurse for an interpretation

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C) Ask the pharmacy for assistance in the interpretation

D) Call the provider for clarification

The correct answer is D: Call the provider for clarification

7. An adult client is found to be unresponsive on morning rounds. After checking for

responsiveness and calling for help, the next action that should be taken by the nurse is

to:

A) check the carotid pulse

B) deliver 5 abdominal thrusts

C) give 2 rescue breaths

D) open the client's airway

The correct answer is D: open the client''s airway

8. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers

that 800 ml has been infused after 4 hours. What is the priority nursing action?

A) Ask the client if there are any breathing problems

B) Have the client void as much as possible

C) Check the vital signs

D) Auscultate the lungs

The correct answer is D: Auscultate the lungs

9. Following change-of-shift report on an orthopedic unit, which client should the nurse

see first?

A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago

B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident

C) 72 year-old recovering from surgery after a hip replacement 2 hours ago

D) 75 year-old who is in skin traction prior to planned hip pinning surgery.

The correct answer is C: 72 year-old recovering from surgery after a hip replacement 2

hours ago

10. A nurse observes a family member administer a rectal suppository by having the

client lie on the left side for the administration. The family member pushed the

suppository until the finger went up to the second knuckle. After 10 minutes the client

was told by the family member to turn to the right side and the client did this. What is the

appropriate comment for the nurse to make?

A) Why don’t we now have the client turn back to the left side.

B) That was done correctly. Did you have any problems with the insertion?

C) Let’s check to see if the suppository is in far enough.

D) Did you feel any stool in the intestinal tract?

The correct answer is B: That was done correctly. Did you have any problems with the

insertion?

11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has

died. Which type of precautions is the appropriate type to use when performing

postmortem care?

A) airborne precautions

B) droplet precautions

C) contact precautions

D) compromised host precautions

The correct answer is C: contact precautions

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