HESI RN EXIT EXAM 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

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nurse for additional teaching?

15. (a) “This weekend we are going to a seafood restaurant.”

(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.”

16. 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

17. 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.”

18. 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

19. 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

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

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

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