HESI RN 2024 EXIT EXAM v1
QUESTIONS AND ANSWERS VERIFIED
100% CORRECT
The nurse is caring for a client with pneumonia who now develops initial signs of septic
shock and multi organ failure. The healthcare provider prescribes a sepsis protocol.
Which intervention is most important for the nurse to include in the plan of care?
A) Maintain strict intake and output.
B) Keep head of bed raised 45°.
C) Excess warmth of extremities.
D) Monitor blood glucose level. - ANSWER A) Maintain strict intake and output.
And adolescent client is admitted to the hospital because of writing a suicide note to a
teacher at school. On the second day of hospitalization, the nurse asked the client to
meet with the treatment team. After the team meeting, the client leaves in tears and
goes to their room. Which nursing intervention is best?
A) Let the client rest quietly in their room for a while.
B) Explore the clients goals and desire for treatment.
C) Ask the treatment team about the clients behavior.
D) Go to the clients room and ask what happened. - ANSWER D) Go to the clients room
and ask what happened.
The healthcare provider prescribes dalteparin 200 units per kilogram subcutaneous
once a day for a client who weighs 154 pounds. The medication is available and 25,000
units per milliliter vial. How many milliliters should the nurse administer? (Enter
numerical value only. If rounding is required, round to the nearest 10th.) - ANSWER 0.6
NGN: The client is a 49-year-old male who reports flu like symptoms including fever
and chest congestion for four days. He came to the emergency department last night
when he was having more difficulty breathing he has a history of 1/2 pack a day
cigarette smoking for 20 years. He has no significant medical or surgical history.
Which two orders should the nurse complete first?
A) Sputum culture.
B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
D) Chest x-ray.
E) Acetominophen 350 mg PO every six hours for temperature control.
F) Run 0.9% sodium chloride IV infusion at 150 mL per hour.
G) Start peripheral IV.
,H) NPO. - ANSWER B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
NGN: 0330: place the client on a cardio respiratory monitor, NPO, sputum culture, start
a peripheral IV infusion, start oxygen 3 L per minute via nasal cannula, begin 0.9%
sodium chloride IV infusion at 150 mL per hour, acetaminophen 350 mg PO every six
hours for temperature.
To start the client on oxygen as ordered which items should the nurse collects from the
supply room? SATA
A) humidifier bottle.
B)Suction canister.
C)Sterile water.
D) Nasal cannula.
E) Flow meter.
F) Lambs wool.
G) Tape. - ANSWER D) Nasal cannula.
E) Flow meter.
NGN: states, I am feeling extremely anxious right now. The client has decreased breath
sounds in the left lower low. His mucus membranes are dry. He has a productive cough
with thick, yellow secretions. His capillary refill is four seconds. Vital signs, temperature
100.2. Heart rate 101 bpm, respiratory rate 28 breaths per minute, blood pressure
145/89, oxygen saturation 90% on room air.
(for each body system click to specify the assessment findings that indicates hypoxia)
Cardiovascular: heart rate 100 bpm, capillary refill for seconds, blood pressure 145/89.
Neurological: anxious, awake and alert, restless.
Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm, productive
cough. - ANSWER Cardiovascular: capillary refill for seconds, blood pressure 145/89.
Neurological: anxious, restless.
Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm.
NGN: The client is a 49-year-old male who reports flu like symptoms including fever
and chest congestion for four days. He came to the emergency department last night
when he was having more difficulty breathing he has a history of 1/2 pack a day
cigarette smoking for 20 years. He has no significant medical or surgical history.
The nurse should place the client in a _______________ position to promote
_____________. - ANSWER Semi-Fowler , lung expansion.
NGN: Orders: 0330: place the client on a cardio respiratory monitor, NPO, sputum
culture, start a PIV, start oxygen 3L via nasal cannula, normal saline 150 ML per hour,
acetaminophen 350mg PO every six hours for temp greater than 101F, chest x-ray.
0500: Oxygen 8Lvia simple facemask, titrate to keep oxygen saturation greater than
94%.
,(mark whether the statements by the new grad nurse indicate understanding or no
understanding of the use of facemask in the care of this client)
-I should clean the facemask once per shift.
-The client should take a 1 to 2 minute break from the facemask each hour.
-I should put gauze under the elastic straps over the ears.
-I can adjust the oxygen level on the flow meter to keep the clients oxygen saturation
greater than 94%.
-The mask should cover only the mouth and leave the nose open for expiration.
-I should place the mask first over the nose and then cover the mouth. - ANSWER -I
should clean the facemask once per shift. (UNDERSTANDING)
-The client should take a 1 to 2 minute break from the facemask each hour. (NOT
UNDERSTANDING)
-I should put gauze under the elastic straps over the ears. (NOT UNDERSTANDING
????)
-I can adjust the oxygen level on the flow meter to keep the clients oxygen saturation
greater than 94%. (UNDERSTANDING)
-The mask should cover only the mouth and leave the nose open for expiration. (NOT
UNDERSTANDING)
-I should place the mask first over the nose and then cover the mouth.
(UNDERSTANDING)
NGN: Nurses Notes: 0400, the client is awake and alert but restless. He states I am
feeling extremely anxious right now. The client has decreased breath sounds in the left
lower lobe. His mucus membranes are dry. He has a productive cough with thick, yellow
secretions. His capillary refill is four seconds. Heart rate 101 BPM, oxygen saturation
90%. Blood pressure 145/89, temperature 100.2 F, respiratory rate 28 BPM.
0500: Placedthe client in semi-Fowlers position. No improvement in oxygen saturation
on 3L nasal cannula...
(Which are the three most important goals?)
A) The client will remain free of skin breakdown.
B) The client will have quit smoking.
C) The client will be afebrile for 24 hours.
D) The client will maintain oxygen saturation of 96% without supplemental oxygen.
E) The client will report pain less than 3/10. - ANSWER B) The client will have quit
smoking.
C) The client will be afebrile for 24 hours.
E) The client will report pain less than 3/10.
The nurse has completed the diet teaching of a client who is being discharged following
treatment of a leg wound. A high-protein diet is encouraged to promote wound healing.
Which lunch toys by the client indicates that the teaching was effective?
, A) A peanut butter sandwich with soda and cookies.
B) Vegetable soup, crackers, and milk.
C) A tuna fish sandwich with chips and ice cream.
D) A salad with three kinds of lettuce and fruit. - ANSWER C) A tuna fish sandwich with
chips and ice cream.
When preparing to administer a prescribed medication to a homeless client at a
community psychiatric clinic. The client tells the nurse that the usual dosage taken is
different from the dose the nurse is giving. Which action should the nurse take?
A) Inform the client that he may refuse the medication and document whether or not the
client takes it.
B) Withhold the medication until the dosage can be confirmed.
C) Explain to the client that the dosage has been changed.
D) Tell the client to take the medication then verify the dosage at the next healthcare
team meeting. - ANSWER B) Withhold the medication until the dosage can be
confirmed.
The charge nurse is making assignments for one practical nurse and three registered
nurses who are caring for neurologically compromised clients. Which client with which
change in status is best to assign to the PN?
A) Subdural hematoma whose blood pressure changed from 150/80 to 170/60.
B) Viral meningitis whose temperature change from 101 S to 102F.
C) Diabetic keto acidosis who is Glasgow coma scale score changed from 10 to 7.
D) Myxedema, whose blood pressure change from 80/50 to 70/40. - ANSWER B) Viral
meningitis whose temperature change from 101 S to 102F.
A client with foul-smelling drainage from an incision on the upper left arm is admitted
with a suspected MRSA. Which nursing intervention should the nurse include in the plan
of care? SATA.
A) Institute contact precautions for staff and visitors.
B) Use standard precautions and wear a mask.
C) Send wound drainage for culture and sensitivity.
D) Monitor the clients white blood cell count.
E) Explain the purpose of a low bacteria diet. - ANSWER A) Institute contact
precautions for staff and visitors.
C) Send wound drainage for culture and sensitivity.
D) Monitor the clients white blood cell count.
An adult client who is admitted to the mental health unit for treatment of bipolar disorder
has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is
most important for the nurse to report to the healthcare provider?
