HESI RN EXIT EXAM COMPREHENSIVE V1 2021 EXAM
A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of the
solution for eight hours, how many ml of full strength feeding will the nurse need? (Enter numeric value
only.) Correct Answer: 200ml . 25 ml of full strength feeding mixed with 25ml of water provided 50ml of
half strength. 25ml × 8 hours= 200ml
An elderly male client is experiencing urinary incontinence. What is the best initial nursing action?
Correct Answer: Apply an external condom catheter
3. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but
refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once
he is cleansed for prayer. What action should the nurse implement? Correct Answer: Reschedule
administration of the antibiotic until after he completes his prayers
UAP using a hand sanitzers that is alcohol for 2 minutes Correct Answer: tell that hand sanitizer use is
less > 2min
5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a scheduled procedure. The
child weighs 44 pounds. How many mg of the medication should the nurse administer Correct Answer:
Answer: 800 Rationale: First, convert the child's weight to kg: 44 pounds divided by
2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg = 800mg
6. While assisting a postpartum client with perineal care, the nurse notes that her vaginal bleeding
spurts rather than trickles from the vagina. The uterine fundus is firm and the client's vital signs are
pulse 88 beats/minute; respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg. What
action should the nurse take next? Correct Answer: Compare current vital signs with previous vital signs
A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his
eye. Which action should the school nurse take? Correct Answer: Have the parent take the child for
emergency help
Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech bizarre
behavior, and strange thoughts about her infant being possessed by demons. The nurse identifies a
nursing diagnosis of "Altered thought processes, secondary to" what condition? Correct Answer:
Postpartum psychosis
The nurse identifies a priority diagnosis of, "Altered comfort related to menstrual cramps" for a 25-year-
old female client. Which self-care activity should the nurse emphasize in the client's teaching plan?
Correct Answer: Regular aerobic exercise.
Psych/Alcohol/Tylenol overdose antidote Correct Answer: Give Mucomyst
Medical Surgical/Laxative abuses Correct Answer: Patient -taking Milk of Magnesium
Spiritual/Documentation Correct Answer: Native American - Allow pt's family to stay in the room
, Leadership- Interpreter informed consent Correct Answer: Pt should sign the consent
Geriatrics/Emergency Rib fractures fall Correct Answer: Pulmonary embolism
A client diagnosed with major depression is being allowed a weekend pass from the psychiatric unit.
Which instruction should the nurse provide to the client's family? Correct Answer: Involve the client in
usual at home activities
Upon assessment, the nurse discovers that a postpartum client has persistent red lochia.
Which of the following does this assessment finding suggest to the nurse? Correct Answer: Coagulation
disorders
The healthcare provider performs peritoneal dialysis on a client, after which 2 liters of fluid is drained.
What action should the nurse complete first? Correct Answer: Assess vital signs.
After administering a medication through a nasogastric tube connected to suction, what action should
the nurse take first? Correct Answer: Clamp the tube
The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.;
Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell count of 15,000.
What
should the nurse implement? Correct Answer: Determine if Client B has two units of packed cells
available in the blood bank.
Triage question with a train wreck The psychiatric nurse is called to a train derailment that was likely
caused by a terrorist bomb. In triaging those in need of immediate care, what is the priority ranking for
these cases?
(arrange these cases in order or priority with the top item requiring the most immediate care and the
bottom item requiring the least priority care) Correct Answer: A mother and father have just arrived on
the .
A crying child being held by another passenger. A woman sitting on the ground with a blanket.
A middle-aged man who is wandering around
(arrange in order) = middle age woman bleeding- woman w/ blanket- child crying- mother and father.
(Mine didn't have a middle age woman bleeding, instead it had an old man wandering and Correct
Answer: correct order is: wandering old man, woman w/blanket, man holding baby, and mother &
father)
The nurse in the emergency department is using the simple triage and rapid transport (START) system to
assess victims of a hurricane. Which statement correctly describes a yellow disaster tag? Correct
Answer: A yellow disaster tag means critical injuries and require immediate intervention.
What makes a baby frontal bulge or rises Correct Answer: crying
Which of the following is a nursing intervention for a 3-year-old client who is going in for sugery in 8
hours
A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of the
solution for eight hours, how many ml of full strength feeding will the nurse need? (Enter numeric value
only.) Correct Answer: 200ml . 25 ml of full strength feeding mixed with 25ml of water provided 50ml of
half strength. 25ml × 8 hours= 200ml
An elderly male client is experiencing urinary incontinence. What is the best initial nursing action?
Correct Answer: Apply an external condom catheter
3. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but
refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once
he is cleansed for prayer. What action should the nurse implement? Correct Answer: Reschedule
administration of the antibiotic until after he completes his prayers
UAP using a hand sanitzers that is alcohol for 2 minutes Correct Answer: tell that hand sanitizer use is
less > 2min
5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a scheduled procedure. The
child weighs 44 pounds. How many mg of the medication should the nurse administer Correct Answer:
Answer: 800 Rationale: First, convert the child's weight to kg: 44 pounds divided by
2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg = 800mg
6. While assisting a postpartum client with perineal care, the nurse notes that her vaginal bleeding
spurts rather than trickles from the vagina. The uterine fundus is firm and the client's vital signs are
pulse 88 beats/minute; respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg. What
action should the nurse take next? Correct Answer: Compare current vital signs with previous vital signs
A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his
eye. Which action should the school nurse take? Correct Answer: Have the parent take the child for
emergency help
Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech bizarre
behavior, and strange thoughts about her infant being possessed by demons. The nurse identifies a
nursing diagnosis of "Altered thought processes, secondary to" what condition? Correct Answer:
Postpartum psychosis
The nurse identifies a priority diagnosis of, "Altered comfort related to menstrual cramps" for a 25-year-
old female client. Which self-care activity should the nurse emphasize in the client's teaching plan?
Correct Answer: Regular aerobic exercise.
Psych/Alcohol/Tylenol overdose antidote Correct Answer: Give Mucomyst
Medical Surgical/Laxative abuses Correct Answer: Patient -taking Milk of Magnesium
Spiritual/Documentation Correct Answer: Native American - Allow pt's family to stay in the room
, Leadership- Interpreter informed consent Correct Answer: Pt should sign the consent
Geriatrics/Emergency Rib fractures fall Correct Answer: Pulmonary embolism
A client diagnosed with major depression is being allowed a weekend pass from the psychiatric unit.
Which instruction should the nurse provide to the client's family? Correct Answer: Involve the client in
usual at home activities
Upon assessment, the nurse discovers that a postpartum client has persistent red lochia.
Which of the following does this assessment finding suggest to the nurse? Correct Answer: Coagulation
disorders
The healthcare provider performs peritoneal dialysis on a client, after which 2 liters of fluid is drained.
What action should the nurse complete first? Correct Answer: Assess vital signs.
After administering a medication through a nasogastric tube connected to suction, what action should
the nurse take first? Correct Answer: Clamp the tube
The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.;
Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell count of 15,000.
What
should the nurse implement? Correct Answer: Determine if Client B has two units of packed cells
available in the blood bank.
Triage question with a train wreck The psychiatric nurse is called to a train derailment that was likely
caused by a terrorist bomb. In triaging those in need of immediate care, what is the priority ranking for
these cases?
(arrange these cases in order or priority with the top item requiring the most immediate care and the
bottom item requiring the least priority care) Correct Answer: A mother and father have just arrived on
the .
A crying child being held by another passenger. A woman sitting on the ground with a blanket.
A middle-aged man who is wandering around
(arrange in order) = middle age woman bleeding- woman w/ blanket- child crying- mother and father.
(Mine didn't have a middle age woman bleeding, instead it had an old man wandering and Correct
Answer: correct order is: wandering old man, woman w/blanket, man holding baby, and mother &
father)
The nurse in the emergency department is using the simple triage and rapid transport (START) system to
assess victims of a hurricane. Which statement correctly describes a yellow disaster tag? Correct
Answer: A yellow disaster tag means critical injuries and require immediate intervention.
What makes a baby frontal bulge or rises Correct Answer: crying
Which of the following is a nursing intervention for a 3-year-old client who is going in for sugery in 8
hours
