HESI EXIT VERSION 3 2020/2021

1. The nurse is reviewing medical prescriptions for newly admitted clients. It would be a

priority for the nurse to follow up with the physician if a client with

(a) a potassium level of 4.5mEq/L has Kayexalate (sodium polystyrene) prescribed

(b) a Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure precautions(c) sensitivity to

Aspirin (acetylsalicylic acid) is prescribed Tylenol (acetaminophen)

(d) sensitivity to Penicillin is prescribed Zithromax (azithromycin)

2. The nurse should intervene if the nurse notes a staff member

(a) obtaining a clients consent prior to their operative procedure after receiving Ativan

(lorazepam)

(b) placing a client on the affected side following surgical repair of a retinal detachment

(c) handling a wet cast with the palms of the hands

(d) using a broad base of support while transferring a client

3. The community health nurse is caring for the following clients. It would be a priority

for the nurse to initiate a multidisciplinary conference for the client who is

(a) 12 years old with Autism who is starting a new school and recently had a

URI (upper respiratory tract infection)

(b) 16 years old, has type 1 Diabetes Mellitus, is unemployed and had a recent Hemoglobin

A1c of 13%

(c) 52 years old, with Myasthenia Gravis, recently prescribed Mestinon

(pyridostigmine) and employed as a mail carrier

(d) 70 years old, has schizophrenia, lives alone and reports hearing non threatening voices.

4. The nurse from the postpartum unit has been temporarily assigned to the medical

surgical unit. It would be most appropriate to assign this nurse to the client who*

(a) has returned from right total hip replacement surgery four hours ago

(b) is being observed for increased intracranial pressure

(c) had surgery two hours ago to remove the appendix

(d) is two weeks post partum being maintained on a mechanical ventilator for respiratory

failure

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5. The nurse in a well baby clinic has assessed several children today. It would be a priority

for the nurse to suggest follow up for the child who is (a) 2 months old with a positive

babinski refl ex

(b) 5 months old and does not hold their own bottle

(c) 10 months old who cries around strangers

(d) 18 months old who needs support while ambulating

6. The nurse is caring for a mechanically ventilated client who was declared brain dead. An

Advance Directive is not documented on the medical record. It would be most appropriate

to obtain consent for organ donation from the

(a) client’s primary care provider

(b) client’s nurse manager

(c) closest living family member

(d) hospital’s ethics committee

7. The nurse has received report on four clients. The nurse should fi rst assess the client

who has*

(a) Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of 90%

(b) Parkinson’s Disease and is demanding to leave the hospital against medical advice

(AMA)

(c) been admitted with suspected Guillian-Barre´ Syndrome and has begun plasmapheresis

therapy

(d) Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+)

8. It would be appropriate to assign which of these tasks to the CNA?

(a) Feeding a client who is experiencing dysphagia

(b) One-on-one client observation for safety

(c) Removal of an indwelling catheter

(d) Performing a simple dressing change

9. The nurse should intervene if a staff member is observed

(a) discussing a client’s diagnosis with visiting family members

(b) collaborating with another nurse to review a prescription for blood transfusion

(c) interrupting other staff members discussing a client in the cafeteria

(d) reviewing a clients lab values with the nutritionist

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10. The nurse is preparing a staff presentation on legal and ethical issues in nursing. The

nurse would be correct to include which of the following examples?

(a) Putting a client in a geriatric chair with the lap tray in front of the client in the day room

to watch television is false imprisonment

(b) Telling a client that you will put in a feeding tube if the client does not eat is an example

of battery

(c) Telling a client with bipolar disorder who is suicidal that they have a right to refuse to

take their medications is an example of malpractice

(d) Placing hands on a client who says “do not touch me” is an example of assault

11. The nurse from the pediatric unit has been temporarily assigned to the Emergency

Department. It would be most appropriate to assign that nurse to the client who*

(a) reports epigastric pain that “feels like indigestion”

(b) has back pain and a pulsating abdominal mass

(c) is HIV+ reporting vomiting and diarrhea

(d) presents with lower abdominal pain and is six weeks pregnant

12. Four clients recently returned to the unit following invasive diagnostic testing. The

nurse should immediately intervene if one of the clients

(a) reports blood tinged sputum following a bronchoscopy

(b) has decreased abdominal girth following paracentesis

(c) reports a headache following a lumbar puncture

(d) is observed flexing and extending the legs two hours after cardiac catheterization

13. The nurse is made aware of the following situations. The nurse should fi rst check the

client who

(a) had a transurethral prostatectomy (TURP) and is reporting urinary dribbling two hours

after the indwelling catheter is removed

(b) has cervical traction and is moving the legs by fl exing and extending the feet

(c) has Alzheimer’s disease (stage 1) and was returned to the room after being found

wandering in the hallway

(d) has a history of partial seizures and is sitting in the bed picking at the clothing and

smacking the lips

14. The nurse in a community health clinic is talking with the parent of a child with Celiac

Disease. Which of the following statements would require follow-up by the nurse for

additional teaching? (a) “This weekend we are going to a seafood restaurant.”

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(b) “I can feed my child oatmeal and eggs for breakfast.”

(c) “My child loves to eat rice and chicken for dinner.”

(d) “Last night we ate fi sh with corn for dinner.”

15. The charge nurse is observing a Licensed Practical Nurse (LPN) performing care for

assigned clients. Follow up will be required if the LPN*: (a) assesses a client’s apical pulse

before administering Digoxin (lanoxin)

(b) elevates the client’s stump on a pillow eight hours after amputation

(c) dons a clean glove on the dominant hand before tracheal suctioning

(d) positions a client on the operative side following a pneumonectomy

16. The nurse at a health promotion fair has taught a group of parents about car seat and seat

belt safety. Which of the following statements, if made by the parent, would indicate a

correct understanding of the information given?

(a) “I will place my newborn infant in a rear facing car seat in the middle of the rear seat.”

(b) “I will wear a lap seat belt high on my belly since I am 8 months pregnant.”

(c) “I can use a front-facing car seat once my baby weighs 15 pounds.”

(d) “I can allow my six-year-old to use a seat belt in the front passenger seat.”

17. The nurse is caring for a client being treated for Vancomycin Resistant

Enterococcus (VRE). The nurse should place the client on

(a) contact precautions

(b) droplet precautions

(c) protective precautions

(d) airborne precautions

18. The nurse is caring for a client with a Vancomycin Resistant Enterococcus (VRE)

wound infection. Which of the following actions would be appropriate for the nurse to

take?

(a) Wear a particulate respirator mask when providing wound care

(b) Instruct visitors not to bring fl owers into the client’s room

(c) Place the client in a private room with negative air pressure

(d) Wear a disposable gown when changing the client’s dressing

19. The nurse should initiate protective precautions for a client who has a

(a) Red Blood Cell Count (RBC) of 3,900/mm3

(b) Platelet count of 400,000μ/L

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