STUDY FOR EXIT HESI/ATI EXAM
ALL HESI EXIT Questions and Answers Test Bank; A+ Rated
Guide (2022)
271. A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily atbedtime.
What action should the nurse take?
(correct Answer- Administer the medication as prescribed with a glass of water
272. Which client should the nurse assess frequently because of the risk foroverflow
incontinence?
A client Who is confused and frequently forgets to go to the bathroom
273. While monitoring a client during a seizure, which interventions should thenurse
implement? (Select all that apply)
(correct Answer-
Move obstacle away from client
Monitor physical movements Observe
for a patent airway Record the duration
of the seizure
274. A male client with a long history of alcoholism is admitted because of mildconfusion
and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking
cigarettes one month ago after his brother died of lung cancer.
Which intervention is most important for the nurses to include in the client's planof care?
(correct Answer- Observe for changes in level of consciousness.
275. An older adult female admitted to the intensive care unit (ICU) with a possible stroke is
intubated with ventilator setting of tidal volume 600, PlO2 40%,and respiratory rate of 12
breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60,
PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding, which action is
required?
correct Answer- Increase ventilator rate.
276. The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing
increasing congestion despite the use of chest physical therapy (CPT)twice a day, and has also
experiences a loss of appetite. What instruction should the nurse provide?
(correct Answer- CPT should be performed more frequently, but at least an hourbefore
meals.
277. The nurse is evaluating the diet teaching of a client with hypertension. What
dinner selection indicates that the client understands the dietary recommendationfor
hypertension?
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,(correct Answer- Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie
278. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and
a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 unitssubcutaneously once a day
at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the
nurse include in this client's plan of care?
(correct Answer- Fingerstick glucose assessment q6h with mealsReview
with the client proper foot care and prevention of injury
Coordinate carbohydrate controlled meals at consistent times and intervals Teach
subcutaneous injection technique, site rotation and insulin management
279. Which problem reported by a client taking lovastatin requires the mostimmediate
fallow up by the nurse?
(correct Answer- Muscle pain
280. While assessing a client's chest tube (CT), the nurse discovers bubbling in thewater seal
chamber of the chest tube collection device. The client's vital signs are: blood pressure of
80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen
saturation 88%. Which interventions should the nurse implement?
(correct Answer- Provide supplemental oxygen
Auscultate bilateral lung fields
Reinforce occlusive CT dressing
281. Before leaving the room of a confused client, the nurse notes that a half bowknot was
used to attach the client's wrist restraints to the movable portion of the client's bed frame.
What action should the nurse take before leaving the room?
(correct Answer- Ensure that the knot can be quickly released.
282. Oral antibiotics are prescribed for an 18-month-old toddler with severe otitismedia. An
antipyrine and benzocaine-otic also prescribed for pain and inflammation. What instruction
should the nurse emphasize concerning the installation of the antipyrine/benzocaine otic
solution?
(correct Answer- Have the child lie with the ear up for one to two minute afterinstallation.
283. An older adult male is admitted with complications related to chronic obstructive
pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion
and his weakness has increased over the past month. Thenurse notes that he has
dependent edema in both lower legs. Based on these assessment findings, which dietary
instruction should the nurse provide?
(correct Answer- Restrict daily fluid intake.
284. The nurse inserts an indwelling urinary catheter as seen in the video whataction
should the nurse take next?
(correct Answer- Leave the catheter in place and obtain a sterile catheter.
285. A client with coronary artery disease who is experiencing syncopal episodesis admitted
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,for an electrophysiology study (EPS) and possible cardiac ablation therapy. Which
intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?
(correct Answer- Prepare the skin for procedure.
286. Fallowing an outbreak of measles involving 5 students in an elementaryschool,
which action is most important for the school nurse to take? (correct Answer- Restrict
unvaccinated children from attending school until measles outbreak is resolved.
287. A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery
room. She continues to receive magnesium sulfate at 2 grams perhour. Her total input is limited
to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention
should the nurse implement?
(correct Answer- Continue with the plan of care for this client
288. The nurse is planning care for a client who admits having suicidal thoughts.Which client
behavior indicates the highest risk for the client acting on these suicidal thoughts?
(correct Answer- Begin to show signs of improvement in affect
289. When assessing a multigravida the first postpartum day, the nurse finds a moderate
amount of lochia rubra, with the uterus firm, and three fingerbreadthsabove the umbilicus.
What action should the nurse implement first?
(correct Answer- Check for a destined bladder
290. A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal
saline at 50 ml/hour. The client's urine specific gravity is 1.035. Whataction should the nurse
implement?
(correct Answer- Encourage popsicles and fluids of choice
291. An older male client arrives at the clinic complaining that his bladder alwaysfeels full. He
complains of weak urine flow, frequent dribbling after voiding, and
increasing nocturia with difficulty initiating his urine stream. Which action shouldthe nurse
implement?
(correct Answer- Palpate the client's suprapubic area for distention
292. The nurse is preparing to administer 1.6 ml of medication IM to a 4 month oldinfant. Which
action should the nurse include?
(correct Answer- Divide the medication into two injection with volumes under1ml
293. A client who had a below the knee amputation is experiencing severe phantom limb
pain (PLP) and ask the nurse if mirror therapy will make the painstop. Which response by
the nurse is likely to be most helpful?
(correct Answer- Research indicates that mirror therapy is effective in reducingphantom
limb pain
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, 294. An older adult client with heart failure (HF) develops cardiac tamponade. Theclient has
muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and
IV hydration, which intervention is most important for the nurse to implement?
(correct Answer- Notify healthcare provider to prepare for pericardiocentesis
295. A new member joins the nursing team spreads books on the table, puts itemson two
chairs, and sits on a third chair. The members of the group are forced to move closer and
remove their possessions from the table what action should the nurse leader take?
(correct Answer- Ask the new person to move belonging to accommodate others
296. The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt
that was placed 2 days after birth. Which findings are an indication of apostoperative
complication?
(correct Answer- Poor feeding and vomiting
Leakage of CSF from the incisional site Abdominal
distention
297. The nurse is preparing a heparin bolus dose of 80 units/kg for a client whoweighs 220
pounds. Heparin sodium injection, USP is available in a 3o ml multidose vial with the
concentration of 1,000 USP units/ml. how many ml of heparin should the nurse administer?
(Enter numeric value only) (
correct Answer- 8
298. In monitoring tissue perfusion in a client following an above the knee amputation
(aka), which action should the nurse include in the plan of care?(correct Answer-
Evaluate closet proximal pulse.
299. The leg of a client who is receiving hospice care have become mottled in appearance.
When the nurse observes the unlicensed assistive personal (UAP) place a heating pad on the
mottled areas, what action should the nurse take? (correct Answer- Remove the heating pads
and place a soft blanket over the client'sleg and feet.
300. A client who underwent an uncomplicated gastric bypass surgery is having difficult with
diet management. What dietary instruction is most important for thenurse to explain to the
client? (correct Answer- Plan volume-controlled evenly- space meal thorough the day
301. If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous
membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a
sodium concentration of 156 mEq/L. What physiologicmechanism contributes to this finding?
(correct Answer- Insensible loss of body fluids contributes to the hemoconcentration of serum
solutes
302. During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN)
who is working with a register nurse (RN) (correct Answer- Prepare a woman for a bone
density screening
303. An adult client present to the clinic with large draining ulcers on both lower legs that are
characteristics of Kaposi's sarcoma lesions. The client is accompaniedby two family member.
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