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HESI Exit QBank / Hesi Exit Test Bank Questions And Answers
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HESI Exit QBank / Hesi Exit Test BankQuestions And Answers
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 Ans - Inability to
close the affected eye, raise brow, or smile
Following discharge teaching, a male client with duodenal ulcer tells the
nurse that he will drink plenty of dairy products, such as milk, to help coat
and protect his ulcer. What is the best follow-up action by the nurse?
Correct Ans - Review with the client the need to avoid foods that are rich in
milk and cream.
Rationale:
Diets rich in milk and cream stimulate gastric acid secretion and should be
avoided.
A male client with hypertension, who received new antihypertensive
prescriptions at his last visit returns to the clinic two weeks later to evaluate
his BP. His BP is 158/106 and he admits that he has not been taking the
prescribed medication because the drugs make him feel bad. In explaining
the need for HTN control, the nurse should stress that an elevated BP places
the client at risk for which pathological condition? Correct Ans - Stroke
secondary to hemorrhage.
Rationale:
Stroke related to cerebral hemorrhage is major risk for uncontrolled HTN.
The nurse observes an unlicensed assistive personnel (UAP) positioning a
newly admitted client who has a seizure disorder. The client is supine and
the UAP is placing soft pillows along the side rails. What action should the
nurse implement? Correct Ans - Instruct the UAP to obtain soft blankets
to secure to the side rails instead of pillows.
Rationale:
The nurse should instruct the UAP to pad the side rails with soft blankets
because the use of pillows could result in suffocation and would need to be
removed at the onset of the seizure. The nurse can delegate paddling the
side rails to the UAP.
An adolescent with major depressive disorder has been taking duloxetine
(Cymbalta) for the past 12 days. Which assessment finding requires
immediate follow-up? Correct Ans - Describes life without purpose.
Rationale:
,Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that
is known to increase the risk of suicidal thinking in adolescents and young
adults with major depressive disorder.
A 60-year-old female client with a positive family history of ovarian cancer
has developed an abdominal mass and is being evaluated for possible
ovarian cancer. Her Papanicolau (Pap) smear results are negative. What
information should the nurse include in the client's teaching plan? Correct
Ans - Further evaluation involving surgery may be needed.
Rationale:
An abdominal mass in a client with a family history for ovarian cancer should
be evaluated carefully.
A client who recently underwent a tracheostomy is being prepared for
discharge to home. Which instructions is most important for the nurse to
include in the discharge plan? Correct Ans - Teach tracheal suctioning
techniques.
Rationale:
Suctioning helps to clear secretions and maintain an open airway, which is
critical.
In assessing an adult client with a partial rebreather mask, the nurse notes
that the oxygen reservoir bag does not deflate completely during inspiration
and the client's respiratory rate is 14 breaths / minute. What action should
the nurse implement? Correct Ans - Document the assessment data.
Rationale:
Reservoir bag should not deflate completely during inspiration and the
client's respiratory rate is within normal limits.
During a home visit, the nurse observes an elderly client with diabetes slip
and fall. What action should the nurse take first? Correct Ans - Check the
client for lacerations or fractures
Rationale:
After the client falls, the nurse should immediately assess for the possibility
of injuries and provide first aid as needed.
At 0600 while admitting a woman for a schedule repeat cesarean section (C-
Section), the client tells the nurse that she drank a cup a coffee at 0400
because she wanted to avoid getting a headache. Which action should the
nurse take first? Correct Ans - Inform the anesthesia care provider.
Rationale:
Surgical preoperative instruction includes NPO after midnight the day of
surgery to decrease the risk of aspiration should vomiting occur during
anesthesia. While it is possible the C-section will be done on schedule or
rescheduled for later in the day, the anesthesia provider should be notified
first.
,After placing a stethoscope as seen in the picture, the nurse auscultates S1
and S2 heart sounds. To determine if an S3 heart sound is present, what
action should the nurse take first? Correct Ans - Listen with the bell at the
same location.
Rationale:
The nurse uses the bell of the stethoscope to hear low-pitched sounds such
as S3 and S4. The nurse listens at the same site using the diaphragm the
diaphragm and bell before moving systematically to the next sites.
A 66-year-old woman is retiring and will no longer have a health insurance
through her place of employment. Which agency should the client be
referred to by the employee health nurse for health insurance needs?
Correct Ans - Medicare.
Rationale:
Title XVII of the social security Act of 1965 created Medicare Program to
provide medical insurance for person more than 65 years or older, disable or
with permanent kidney failure, WIC provides supplemental nutrition to meet
the needs of pregnant of breastfeeding woman, infants and children up to
age of 6. Medicaid provides financial assistance to pay for medical services
for poor older adults, blind, disable and families with dependent children.
COBRA(D) health benefit provisions is a limited insurance plan for those who
has been laid off or become unemployed.
A client who is taking an oral dose of a tetracycline complains of
gastrointestinal upset. What snack should the nurse instruct the client to
take with the tetracycline? Correct Ans - Toasted wheat bread and jelly.
Rationale:
Dairy products decrease the effect of tetracycline, so the nurse instructs the
client to eat a snack such as toast, which contains no dairy products and
may decrease GI symptoms.
Following a lumbar puncture, a client voices several complaints. What
complaint indicated to the nurse that the client is experiencing a
complication? Correct Ans - "I have a headache that gets worse when I sit
up."
Rationale:
A post-lumbar puncture headache, ranging from mild to severe, may occur
as a result of leakage of cerebrospinal fluid at the puncture site. This
complication is usually managed by bedrest, analgesic, and hydration.
An elderly client seems confused and reports the onset of nausea, dysuria,
and urgency with incontinence. Which action should the nurse implement?
Correct Ans - Obtain a clean catch midstream specimen.
Rationale:
, This elderly is experiencing symptoms of urinary tract infection. The nurse
should obtain a clean catch midstream specimen to determine the causative
agent so an anti-infective agent can be prescribed.
The nurse is assisting the mother of a child with phenylketonuria (PKU) to
select foods that are in keeping with the child's dietary restrictions. Which
foods are contraindicated for this child? Correct Ans - Foods sweetened
with aspartame.
Rationale:
Aspartame should not be consumed by a child with PKU because ut is
converted to phenylalanine in the body. Additionally, milk and milk products
are contraindicated for children with PKU.
Before preparing a client for the first surgical case of the day, a part-time
scrub nurse asks the circulating nurse if a 3-minute surgical hand scrub is
adequate preparation for this client. Which response should the circulating
nurse provide? Correct Ans - Direct the nurse to continue the surgical
hand scrub for a 5- minute duration.
Rationale:
The surgical hand scrub should last for 5 to 10 mins, so the nurse should be
directed to continue the vigorous scrub using a reliable agent for the total
duration of 5 mins.
Which breakfast selection indicates that the client understands the nurse‟s
instructions about the dietary management of osteoporosis? Correct Ans -
Bagel with jelly and skim milk.
Rationale:
Includes dairy products which contain calcium and does not include any
foods that inhibit calcium absorption. The primary dietary implication of
osteoporosis is the need for increased calcium and reduction in foods that
decrease calcium absorption, such as caffeine and excessive fiber.
The charge nurse of a critical care unit is informed at the beginning of the
shift that less than the optimal number of registered nurses will be working
that shift. In planning assignments, which client should receive the most care
hours by a registered nurse (RN)? Correct Ans - An 82-year-old client with
Alzheimer's disease newly-fractures femur who has a Foley catheter and soft
wrist restraints applied.
Rationale:
Describe the client at the most risk for injury and complications because of
the factor listed.
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot,
I have been applying triple antibiotic ointment for two days, but there has
been no improvement." What instruction should the nurse provide? Correct
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