HESI 2019 EXIT RN Version 3.
1. Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is
transferred to the neuro intensive care unit with a temperature of 102 F axillary, pulse of 180 beats/minute, and
a blood pressure of 90/60 mmHg. Which is the priority intervention to include in this client’s plan of care?
A. Keep the suture line clean and dry.
B. Check neuro vital signs every 4 hours.
C. Maintain intravenous access.
D. Measure hourly urine output.
ANS: C
2. A client presents at the emergency department reporting a raspy voice, cold intolerance, and fatigue.
Laboratory tests indicate an elevated thyroid stimulating hormone (TSH) and low T3 and T4 levels. After the
client is admitted to the telemetry unit, which interventions is most important for the nurse to implement?
A. Note the client’s most recent hemoglobin level.
B. Administer prescribed dose of levothyroxine.
C. Offer additional blankets and a warm drink.
D. Assess for presence of non-pitting edema.
ANS: B
3. The nurse observes an unlicensed assistive personnel (UAP) begin to remove exam gloves after emptying a
bed pan containing feces. The UAP slides two fingers inside one of the gloves and begins to roll the glove off.
Which actions should the nurse implement?
A. Instruct the UAP to use two pairs of gloves when fecal contamination is likely.
B. Remind the UAP to discard the gloves in the biohazard contain after removal.
C. Support that the UAP roll both of the gloves and inside out at the same time.
D. Advice the UAP that the technique being used will result in hand contamination.
ANS: D
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4. A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated, and the
client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess effectiveness of the
fluid bolus?
A. Mean arterial pressure (MAP)
B. White blood cell count
C. Blood culture
D. Oxygen saturation
ANS: D
5. In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should
the nurse include in the plan of care?
A. Evaluate closet proximal pulse.
B. Asses skin elasticity of the stump.
C. Observe for swelling around the stump.
D. Note amount color of wound drainage.
ANS: A
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6. An older adult client is admitted to the intensive care unit unconscious after several days of vomiting and
diarrhea. The nurse inserts a urinary catheter and obtains a scant amount of dark amber output. Which
interventions should the nurse implement first? (Please scroll and view each tab’s information in the client’s
medical record before selecting the answer.)
Flow Sheets
Vital Signs
Heart Rate – beats/minute 110
Respirations – breaths/minute 28
Blood Pressure – mmHG 80/60
Laboratory
Electrolytes
Sodium – 1.30 mEq/L
Potassium – 2.5 mEq/L
Chloride – 95 mEq/L
Diagnostics
Arterial blood gases (ABGs)
pH – 7.34
PaCO2 – 34 mmHg
HCO3 - 20 mEq/L
po2 – 90 mmHg
A. Initiate continuous dopamine infusion at2 mcg/kg/minute.
B. Give bolus of 0.9% sodium chloride 1,000 ml over 30 minutes.
C. Administer promethazine 2.5 mg slowly IV push q4.
D. Begin potassium chloride 10 mEq over 1 hour per secondary infusion.
ANS: B
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7. The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff
and has been in a sustained vegetative state since the accident. Which interventions should the nurse
implement?
A. Initiate open communication with the teen’s parents.
B. Talk directly to the adolescent while providing care.
C. Inquire about food allergies and food likes and dislikes.
D. Monitor vital signs and neuro status every 2 hours.
ANS: B
8. A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes Mellitus and
hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the
most important for the nurse to include in this client’s plan of care?
A. Monitor the client’s cardiac activity via telemetry.
B. Maintain venous access with an infusion of normal saline.
C. Assess glucose via fingerstick q4 to 6 hours.
D. Evaluate hourly urine output for return of normal renal function.
ANS: A
9. A middle aged male client, admitted to a critical care unit several weeks ago because of serious injuries
sustained in a motor vehicle accident, is currently in stable condition. Based on this client’s age and recent lifethreatening crisis, which intervention is should the nurse implement?
A. Allow long periods of uninterrupted rest in order to reduce fatigue.
B. Encourage the client to reflect on personal goals and priorities.
C. Provide a routine schedule of activities to fascinate trust.
D. Discuss the cause of the accident with the client and his family.
ANS: B
10. A client is receiving the intravenous adrenergic agonist dobutamine. In evaluating the client’s reaction to the
medication, which assessment findings indicates to the nurse that the medication is effective?
A. The client denies chest pain or discomfort.
B. The client had 160 ml urine output in 8 hours.
C. The client’s posterior tibial pulses are 1 +.
D. The client’s blood pressure is 110/70 mmHg.
ANS: A
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Version | 2021 |
Category | HESI |
Pages | 47 |
Language | English |
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