NUR4311 HESI EXIT RN EXAM V3 2022 (NEW)
1. After placing a 36- week- gestation newborn in an isolette and drying the
infant with several blankets, what should the nurse implement next?
a. Place erythromycin ophthalmic ointment in both eyes
2. A client in the third trimester of pregnancy complains of frequent nasal
stiffness and occasional nosebleeds. Her chest circumference has increased
by 5 cm during the pregnancy, and she uses thoracic breathing. Her
diaphragm is elevated and she has an increased costal angle. Which
intervention should the nurse implement?
a. Examine the client for signs of tissue anoxia, such as pallor
3. A terminally ill male hospice client who is at home is showing decreased
awareness of his surroundings. His appetite is poor and he often refuses oral
intake of solids and liquids. For the past several days he has been unable to
get out of bed. Which action should the hospice nurse implement?
a. Teach the family how to assist the client to a wheelchair
4. A woman was admitted yesterday afternoon with severe abdominal pain. Her
pregnancy test and ultrasound were negative, so an exploratory laparotomy
was completed during the night. When coffee ground materials is observed in
the drainage from the nasogastric tube (NGT), which intervention should the
nurse implement?
a. Verify correct placement of the nasogastric tube
5. The nurse is reviewing the laboratory values for a client with acute
pancreatitis who reports of the abdominal pain is not as severe as it was on
admission. Which laboratory test should the nurse review to evaluate the
clients clinical recovery?
a. Lipase
6. While assessing a client who had a laparotomy the previous day, the nurse
notices that 300 mL of dark red fluid has drained from the nasogastric tube in
the last hour. Which action should the nurse take first?
a. Assess the clients level of pain
7. The nurse is reviewing the recommended preventative care for clients with
asthma, chronic bronchitis, and emphysema. Which health care measure is
most important for the nurse to recommend to these clients?
a. Avoid large crowded areas during the colder months of the year
8. The mother of a one-moth-old infant calls the clinic to report that the back of
her infant’s head is flat. How should the nurse respond?
a. Position the infant on the stomach occasionally when awake and
active
9. A woman is brought to the labor and delivery unti after delivering a term
infant and the placenta in the hospital parking lot 10 minutes ago. Which
action should the nurse perform first?
a. Place the infant to the breast for bonding
10. A client has a new prescription for the maximum recommended dosage of
pipercillin/tazobactam for nosocomial pneumonia. The nurse should report
which laboratory finding to the healthcare provider before administering the
prescribed dose?
a. Presence of gram positive bacteria in the sputum
, 11. A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating
Kussmaul breathing and has a severe headache along with nausea. Her
arterial blood gases (ABG) are: pH 7.50; PaCO2 30 mmHg; HCO3 24 mEq/L
(24mmol/L). Which assessment finding warrants immediate intervention by
the nurse?
a. Fruity breath
12. When perfomring postural drainage on a client with Chronic Obstructive
Pulmonary disease (COPD), which approach should the nurse use?
a. Expalin that the client may be placed in five positions
13. A young male client with testicular cancer has a living will that describes his
desire that no extraordinary measures be taken to save his life. The
healthcare provider knows the client has a good prognosis and refuses to
write a “do not resuscitate” (DNR) prescription. Which action should the
nurse take?
a. Place a DNR bracelet on the clients arm
14. In observing a clients face, which assessment finding requires the most
immediate intervention by the nurse?
a. Oral mucosa is cyanotic
15. The nurse is assessing a client with cirrhosis and notes that the client has a
positive Babinski reflex. Which action should the nurse take in response to
the finding?
a. Complete a thorough neurological assessment
16. Which action should the nurse take first after obtaining a urine specimen for
culture and sensitivity from an indwelling urinary catheter?
a. Label the container with the client’s identifiers
17. The home health nurse observes an older client with unilateral weakness
place the walker in front of the chair for support while rising to a standing
position. Which action should the nurse take?
a. Instruct the client to use the arms of the chair for support
18. A client with cancer complains of fever, chills, malaise, and headache
following administration of a colony-stimulating factor. Which nursing
intervention is most beneficial in helping to reduce the flu-like symptoms?
a. Monitor lab values for an increase in WBCs
19. Which laboratory value should the nurse review prior to administering the
initial dose of a statin medication?
a. Serum liver enzymes
20. Following a lumbar puncture, a client voices several concerns. Which concern
indicates to the nurse that the client is experiencing a complication of the
procedure?
a. I have a headache that gets worse when I sit up
21. The nurse is caring for a client withdrawing from a fentanyl citrate addiction.
The client receives a prescription for clonidine 0.2 mg PO taken twice daily.
Which action should the nurse take?
a. Advise to sit up slowly from a reclining position
1. After placing a 36- week- gestation newborn in an isolette and drying the
infant with several blankets, what should the nurse implement next?
a. Place erythromycin ophthalmic ointment in both eyes
2. A client in the third trimester of pregnancy complains of frequent nasal
stiffness and occasional nosebleeds. Her chest circumference has increased
by 5 cm during the pregnancy, and she uses thoracic breathing. Her
diaphragm is elevated and she has an increased costal angle. Which
intervention should the nurse implement?
a. Examine the client for signs of tissue anoxia, such as pallor
3. A terminally ill male hospice client who is at home is showing decreased
awareness of his surroundings. His appetite is poor and he often refuses oral
intake of solids and liquids. For the past several days he has been unable to
get out of bed. Which action should the hospice nurse implement?
a. Teach the family how to assist the client to a wheelchair
4. A woman was admitted yesterday afternoon with severe abdominal pain. Her
pregnancy test and ultrasound were negative, so an exploratory laparotomy
was completed during the night. When coffee ground materials is observed in
the drainage from the nasogastric tube (NGT), which intervention should the
nurse implement?
a. Verify correct placement of the nasogastric tube
5. The nurse is reviewing the laboratory values for a client with acute
pancreatitis who reports of the abdominal pain is not as severe as it was on
admission. Which laboratory test should the nurse review to evaluate the
clients clinical recovery?
a. Lipase
6. While assessing a client who had a laparotomy the previous day, the nurse
notices that 300 mL of dark red fluid has drained from the nasogastric tube in
the last hour. Which action should the nurse take first?
a. Assess the clients level of pain
7. The nurse is reviewing the recommended preventative care for clients with
asthma, chronic bronchitis, and emphysema. Which health care measure is
most important for the nurse to recommend to these clients?
a. Avoid large crowded areas during the colder months of the year
8. The mother of a one-moth-old infant calls the clinic to report that the back of
her infant’s head is flat. How should the nurse respond?
a. Position the infant on the stomach occasionally when awake and
active
9. A woman is brought to the labor and delivery unti after delivering a term
infant and the placenta in the hospital parking lot 10 minutes ago. Which
action should the nurse perform first?
a. Place the infant to the breast for bonding
10. A client has a new prescription for the maximum recommended dosage of
pipercillin/tazobactam for nosocomial pneumonia. The nurse should report
which laboratory finding to the healthcare provider before administering the
prescribed dose?
a. Presence of gram positive bacteria in the sputum
, 11. A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating
Kussmaul breathing and has a severe headache along with nausea. Her
arterial blood gases (ABG) are: pH 7.50; PaCO2 30 mmHg; HCO3 24 mEq/L
(24mmol/L). Which assessment finding warrants immediate intervention by
the nurse?
a. Fruity breath
12. When perfomring postural drainage on a client with Chronic Obstructive
Pulmonary disease (COPD), which approach should the nurse use?
a. Expalin that the client may be placed in five positions
13. A young male client with testicular cancer has a living will that describes his
desire that no extraordinary measures be taken to save his life. The
healthcare provider knows the client has a good prognosis and refuses to
write a “do not resuscitate” (DNR) prescription. Which action should the
nurse take?
a. Place a DNR bracelet on the clients arm
14. In observing a clients face, which assessment finding requires the most
immediate intervention by the nurse?
a. Oral mucosa is cyanotic
15. The nurse is assessing a client with cirrhosis and notes that the client has a
positive Babinski reflex. Which action should the nurse take in response to
the finding?
a. Complete a thorough neurological assessment
16. Which action should the nurse take first after obtaining a urine specimen for
culture and sensitivity from an indwelling urinary catheter?
a. Label the container with the client’s identifiers
17. The home health nurse observes an older client with unilateral weakness
place the walker in front of the chair for support while rising to a standing
position. Which action should the nurse take?
a. Instruct the client to use the arms of the chair for support
18. A client with cancer complains of fever, chills, malaise, and headache
following administration of a colony-stimulating factor. Which nursing
intervention is most beneficial in helping to reduce the flu-like symptoms?
a. Monitor lab values for an increase in WBCs
19. Which laboratory value should the nurse review prior to administering the
initial dose of a statin medication?
a. Serum liver enzymes
20. Following a lumbar puncture, a client voices several concerns. Which concern
indicates to the nurse that the client is experiencing a complication of the
procedure?
a. I have a headache that gets worse when I sit up
21. The nurse is caring for a client withdrawing from a fentanyl citrate addiction.
The client receives a prescription for clonidine 0.2 mg PO taken twice daily.
Which action should the nurse take?
a. Advise to sit up slowly from a reclining position
