HESI Exit Exam 2023
While assessing a radial artery catheter, the client complains of
numbness and pain distal to the insertion site. What interventions
should the nurse implement? - CORRECT ANSWER Promptly remove
the arterial catheter from the radial artery. A client is admitted with
an epidural hematoma that resulted from a skateboarding accident.
To differentiate the vascular source of the intracranial bleeding,
which finding should the nurse monitor? - CORRECT ANSWER Rapid
onset of decreased level of consciousness. When preparing a client
for discharge from the hospital following a cystectomy and a urinary
diversion to treat bladder cancer, which instruction is most
important for the nurse to include in the client's discharge teaching
plan? - CORRECT ANSWER Report any signs of cloudy urine output.
After repositioning an immobile client, the nurse observes an area of
hyperemia. To assess for blanching, what action should the nurse
take? - CORRECT ANSWER Apply light pressure over the area. The
nurse enters a client's room and observes the client's wrist restraint
secured as seen in the picture. What action should the nurse take? -
CORRECT ANSWER Reposition the restraint tie onto the bedframe. A
female client with acute respiratory distress syndrome (ARDS) is
chemically paralyzed and sedated while she is on as assist-control
ventilator using 50% FIO2. Which assessment finding warrants
immediate intervention by the nurse? - CORRECT ANSWER
Diminished left lower lobe sounds Rationale: Diminished lobe sounds
indicate collapsed alveoli or tension pneumothorax, which required
immediate chest tube insertion to re-inflate the lung. The
development of atherosclerosis is a process of sequential events.
Arrange the pathophysiological events in orders of occurrence.
(Place the first event on top and the last on the bottom) - CORRECT
ANSWER Arterial endothelium injury causes inflammation
Macrophages consume low density lipoprotein (LDL), creating foam
cells Foam cells release growth factors for smooth muscle cells
Smooth muscle grows over fatty streaks creating fibrous plaques
Vessel narrowing results in ischemia Following a motor vehicle
collision, an adult female with a ruptured spleen and a blood
pressure of 70/44, had an emergency splenectomy. Twelve hours
after the surgery, her urine output is 25 ml/hour for the last two
hours. What pathophysiological reason supports the nurse's decision
to report this finding to the healthcare provider? - CORRECT
ANSWER Oliguria signals tubular necrosis related to hypoperfusion A
nurse-manager is preparing the curricula for a class for charge
nurses. A staffing formula based on what data ensures quality client
care and is most cost-effective? - CORRECT ANSWER Skills of staff
and client acuity When performing postural drainage on a client with
Chronic Obstructive Pulmonary Disease (COPD), which approach
should the nurse use? - CORRECT ANSWER Explain that the client
may be placed in five positions A client presents in the emergency
room with right-sided facial asymmetry. The nurse asks the client to
,perform a series of movements that require use of the facial
muscles. What symptoms suggest that the client has most likely
experience a Bell's palsy rather than a stroke? - CORRECT ANSWER
Inability to close the affected eye, raise brow, or smile The nurse is
teaching a client how to perform colostomy irrigations. When
observing the client's return demonstration, which action indicated
that the client understood the teaching? - CORRECT ANSWER Keeps
the irrigating container less than 18 inches above the stoma The
nurse should teach the client to observe which precaution while
taking dronedarone? - CORRECT ANSWER Avoid grapefruits and its
juice A client who sustained a head injury following an automobile
collision is admitted to the hospital. The nurse include the client's
risk for developing increased intracranial pressure (ICP) in the plan
of care. Which signs indicate to the nurse that ICP has increased? -
CORRECT ANSWER Increased Glasgow coma scale score. Nuchal
rigidity and papilledema. Confusion and papilledema Periorbital
ecchymosis. Rationale: papilledema is always an indicator of
increased ICP, and confusion is usually the first sign of increased
ICP. Other options do not necessarily reflect increased ICP. The
nurse is caring for a client receiving continuous IV fluids through a
single lumen central venous catheter (CVC). Based on the CVC care
bundle, which action should be completed daily to reduce the risk
for infection? - CORRECT ANSWER Confirm the necessity for
continued use of the CVC. During an annual physical examination,
an older woman's fasting blood sugar (FBS) is determined to be 140
mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a
follow-up visit 2 weeks later is most indicative that the client has
diabetes mellitus (DM)? - CORRECT ANSWER Repeated fasting blood
sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI). A client who was
admitted yesterday with severe dehydration is complaining of pain a
24 gauge IV with normal saline is infusing at a rate of 150 ml/hour.
Which intervention should the nurse implement first? - CORRECT
ANSWER Stop the normal saline infusion. An elderly female is
admitted because of a change in her level of sensorium. During the
evening shift, the client attempts to get out bed and falls, breaking
her left hip. Buck's skin traction is applied to the left leg while
waiting for surgery. Which intervention is most important for the
nurse to include in this client's plan care? - CORRECT ANSWER
Ensure proper alignment of the leg in traction. A client who had a
right hip replacement 3 day ago is pale has diminished breath sound
over the left lower lung fields, a temperature of 100.2 F, and an
oxygen saturation rate of 90%. The client is scheduled to be
transferred to a skilled nursing facility (SNF) tomorrow for
rehabilitative critical pathway. Based on the client's symptoms,
what recommendation should the nurse give the healthcare
provider? - CORRECT ANSWER Reassess readiness for SNF transfer.
A client who is newly diagnosed with type 2 diabetes mellitus (DM)
receives a prescription for metformin (Glucophage) 500 mg PO twice
daily. What information should the nurse include in this client's
,teaching plan? (Select all that apply.) - CORRECT ANSWER
Recognize signs and symptoms of hypoglycemia. Report persist
polyuria to the healthcare provider. Take Glucophage with the
morning and evening meal. The nurse is developing an educational
program for older clients who are being discharged with new
antihypertensive medications. The nurse should ensure that the
educational materials include which characteristics? Select all that
apply - CORRECT ANSWER Written at a twelfth grade reading level
Contains a list with definitions of unfamiliar terms Uses common
words with few Syllables Printed using a 12 point type font Uses
pictures to help illustrate complex ideas Rationale: During the aging
process older clients often experience sensory or cognitive changes,
such as decreased visual or hearing acuity, slower thought or
reasoning processes, and shorter attention span. Materials for this
age group should include at least of terms, such as a medical
terminology that incline may not know and use common words that
expresses information clearly and simply. Simple, attractive pictures
help hold the learner's attention. The reading level of material
should be at the 4th to 5th grade level. Materials should be printed
using large font (18-point or higher), not the standard 12-point font.
During the admission assessment, the nurse auscultates heart
sounds for a client with no history of cardiovascular disease. Where
should the nurse listen when assessing the client's point of maximal
impulse (PMI) (Click the chosen location. To change, click on a new
location) - CORRECT ANSWER Left Fourth Intercostal Space An older
male adult resident of long-term care facility is hospitalized for a
cardiac catheterization that occurred yesterday. Since the
procedure was conducted, the client has become increasingly
disoriented. The night shift nurse reports that he attempted to
remove the sandbag from his femoral artery multiple times during
the night. What actions should the nurse take? (Select all that
apply.) - CORRECT ANSWER Notify the healthcare provider of the
client's change in mental status. Include q2 hour's reorientation in
the client's plan of care. An older male comes to the clinic with a
family member. When the nurse attempts to take the client's health
history, he does not respond to questions in a clear manner. What
action should the nurse implement first? - CORRECT ANSWER Assess
the surroundings for noise and distractions. The nurse caring for a
client with acute renal fluid (ARF) has noted that the client has
voided 800 ml of urine in 4 hours. Based on this assessment, what
should the nurse anticipate that client will need? - CORRECT
ANSWER Large amounts of fluid and electrolyte replacement. Which
intervention should the nurse include in the plan of care for a child
with tetanus? - CORRECT ANSWER Minimize the amount of stimuli in
the room Suicide precautions are initiated for a child admitted to the
mental health unit following an intentional narcotic overdose. After
a visitor leaves, the nurse finds a package of cigarettes in the
client's room. Which intervention is most important for the nurse to
implement? - CORRECT ANSWER Remove cigarettes for the client's
, room A family member of a frail elderly adult asks the nurse about
eligibility requirements for hospice care. What information should
the nurse provide? (Select all that apply.) - CORRECT ANSWER A
client must be willing to accept palliative care, not curative care.
The healthcare provider must project that the client has 6 months or
less to live. A client with atrial fibrillation receives a new prescription
for dabigatran. What instruction should the nurse include in this
client's teaching plan? - CORRECT ANSWER Avoid use of
nonsteroidal ant-inflammatory drugs (NSAID). A nurse with 10 years
experience working in the emergency room is reassigned to the
perinatal unit to work an 8 hour shift. Which client is best to assign
to this nurse? - CORRECT ANSWER A mother with an infected
episiotomy An infant who is admitted for surgical repair of a
ventricular septal defect (VSD) is irritable and diaphoretic with
jugular vein distention. Which prescription should the nurse
administer first? - CORRECT ANSWER Digoxin. The nursing staff on a
medical unit includes a registered nurse (RN), practical nurse (PN),
and an unlicensed assistive personnel (UAP). Which task should the
charge nurse assign to the RN? - CORRECT ANSWER Supervise a
newly hired graduate nurse during an admission assessment. While
teaching a young male adult to use an inhaler for his newly
diagnosed asthma, the client stares into the distance and appears to
be concentrating on something other than the lesson the nurse is
presenting. What action should the nurse take? - CORRECT ANSWER
Ask the client what he is thinking about at his time. After several
hours of non-productive coughing, a client presents to the
emergency room complaining of chest tightness and shortness of
breath. History includes end stage chronic obstructive pulmonary
disease (COPD) and diabetes mellitus. While completing the
pulmonary assessment, the nurse hears wheezing and poor air
movement bilaterally. Which actions should the nurse implement?
(Select all that apply.) - CORRECT ANSWER Administer PRN
nebulizer treatment. Obtain 12 lead electrocardiogram. Monitor
continuous oxygen saturation. The nurse caring for a 3-month-old
boy one day after a pylorotomy notices that the infant is restless, is
exhibiting facial grimaces, and is drawing his knees to his chest.
What action should the nurse take? - CORRECT ANSWER Administer
a prescribed analgesia for pain. A 4-year-old with acute lymphocytic
leukemia (ALL) is receiving a chemotherapy (CT) protocol that
includes methotrexate (Mexate, Trexal, MIX), an antimetabolite.
Which information should the nurse provide the parents about
caring for their child? - CORRECT ANSWER Use sunblock or
protective clothing when outdoors. Two days after admission a male
client remembers that he is allergic to eggs, and informs the nurse
of the allergy. Which actions should the nurse implement? (Select all
that apply) - CORRECT ANSWER Notify the food services department
of the allergy. Enter the allergy information in the client's record.
Add egg allergy to the client's allergy arm band. The rapid response
team's detects return of spontaneous circulation (ROSC) after 2 min
