EXIT HESI - Comprehensive PN Exam A
Practice Questions
A nurse who has recently completed orientation is beginning work in the labor and delivery
unit for the first time. When making assignments, which client should the charge nurse
assign to this new nurse? - ANSA multiparous client who is dilated 5 cm and 50% effaced
A client with human immunodeficiency virus (HIV) infection has white lesions in the oral
cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish
and swallow. Which information is most important for the nurse to provide the client? -
ANSOral hygiene should be performed before the medication.
A client who is admitted with emphysema is having difficulty breathing. In which position
should the nurse place the client? - ANSSitting upright and forward with both arms supported
on an over the bed table
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ)
PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's
serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium
level? - ANSThe client's renal function has affected his potassium level.
A registered nurse (RN) delivers telehealth services to clients via electronic communication.
Which nursing action creates the greatest risk for professional liability and has the potential
for a malpractice lawsuit? - ANSSending medical records to health care providers via the
Internet
Which pathophysiologic response supports the contraindication for opioids, such as
morphine, in clients with increased intracranial pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated.
B.Higher doses of opioids are required when cerebral blood flow is reduced by an elevated
ICP.
C.Dysphoria from opioids contributes to altered levels of consciousness with an elevated
ICP.
D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP. -
ANSD
The greatest risk associated with opioids such as morphine (D) is respiratory depression that
causes an increase in Pco2, which increases ICP and masks the early signs of intracranial
bleeding in head injury. (A, B, and C) do not support the risks associated with opioid use in a
client with increased ICP.
The charge nurse of a medical surgical unit is alerted to an impending disaster requiring
implementation of the hospital's disaster plan. Specific facts about the nature of this disaster
,are not yet known. Which instruction should the charge nurse give to the other staff
members at this time?
A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
D.Continue with current assignments until more instructions are received. - ANSD
When faced with an impending disaster, hospital personnel may be alerted but should
continue with current client care assignments until further instructions are received (D).
Evacuation is typically a response of last resort that begins with clients who are most able to
ambulate (A). (B) is premature and is likely to increase the chaos if incoming casualties are
anticipated. (C) is poor utilization of personnel.
The nurse assesses a client while the UAP measures the client's vital signs. The client's vital
signs change suddenly, and the nurse determines that the client's condition is worsening.
The nurse is unsure of the client's resuscitative status and needs to check the client's
medical record for any advanced directives. Which action should the nurse implement?
A.Ask the UAP to check for the advanced directive while the nurse completes the
assessment.
B.Assign the UAP to complete the assessment while the nurse checks for the advanced
directive.
C.Check the medical record for the advanced directive and then complete the client
assessment.
D.Call for the charge nurse to check the advanced directive while continuing to assess the
client. - ANSD
Because the client's condition is worsening, the nurse should remain with the client and
continue the assessment while calling for help from the charge nurse to determine the
client's resuscitative status (D). (A and B) are tasks that must be completed by a nurse and
cannot be delegated to the UAP. (C) is contraindicated.
The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the nurse.
Which task is important for the nurse to perform, rather than the UAP?
A.Remove the client's nail polish and dentures.
B.Assist the client to the restroom to void.
C.Obtain the client's height and weight.
D.Offer the client emotional support. - ANSD
By using therapeutic techniques to offer support (D), the nurse can determine any client
concerns that need to be addressed. (A, B, and C) are all actions that can be performed by
the UAP under the supervision of the nurse.
Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel
(UAP) who usually works in labor and delivery and the newborn nursery is assigned to work
on the postoperative unit. Which client would be best for the charge nurse to assign to this
UAP?
A.An adolescent who was readmitted to the hospital because of a postoperative infection
, B.A woman with a new colostomy who requires discharge teaching
C.A woman who had a hip replacement and may be transferred to the home care unit
D.A man who had a cholecystectomy and currently has a nasogastric tube set to
intermittent suction - ANSC
The charge nurse will be responsible for providing a report to the home care unit if the
transfer occurs (A). The client is infected and an employee who works on an OB unit should
be assigned to clean cases in case the employee is required to return to the OB unit (B).
This requires the skills of a registered nurse (RN) to do discharge teaching and provide
emotional support (D). This may require skills beyond the level of this UAP.
A male client is admitted for observation after being hit on the head with a baseball bat. Six
hours after admission, the client attempts to crawl out of bed and asks the nurse why there
are so many bugs in his bed. His vital signs are stable, and the pulse oximeter reading is
98% on room air. Which intervention should the nurse perform first?
A.Administer oxygen per nasal cannula at 2 L/min.
B.Plan to check his vital signs again in 30 minutes.
C.Notify the health care provider of the change in mental status.
D.Ask the client why he thinks there are bugs in the bed. - ANSC
One of the earliest signs of increased intracranial pressure (ICP) is a change in mental
status (C). It is important to act early and quickly when symptoms of increased ICP occur.
Because his oxygen saturation is normal, the administration of oxygen (A) is not the top
priority. Vital signs should be monitored frequently (B), but the client's confusion should be
reported immediately. (D) is not a useful intervention.
The nurse is monitoring a client who is receiving bedside conscious sedation with midazolam
hydrochloride (Versed). In assessing the client, the nurse determines that the client has
slurred speech with diplopia. Based on this finding, what action should the nurse take?
A.Open the airway with a chin lift-head tilt maneuver.
B.Obtain a fingerstick glucose reading.
C.Administer flumazenil (Romazicon).
D.Continue to monitor the client. - ANSD
The desired level III in conscious sedation includes slurred speech, glazed eyes, and
marked diplopia. Because this is the desired outcome of the medication regimen, no action
is needed but continuing to monitor the client (D). The airway is open if the client is able to
talk (A). There are no signs of hypoglycemia (B). No reversal is necessary for the
benzodiazepine (Versed) without signs of oversedation, such as respiratory depression (C).
The nurse is assessing a client using the Snellen chart and determines that the client's visual
acuity is the same as in a previous examination, which was recorded as 20/100. When the
client asks the meaning of this, which information should the nurse provide?
A.This visual acuity result is five times worse that of a normal finding.
B.This line should be seen clearly when the client wears corrective lenses.
C.A client with normal vision can read at 100 feet what this client reads at 20 feet.
D.This client can see at 100 feet what a client with normal vision can see at 20 feet. - ANSC
Practice Questions
A nurse who has recently completed orientation is beginning work in the labor and delivery
unit for the first time. When making assignments, which client should the charge nurse
assign to this new nurse? - ANSA multiparous client who is dilated 5 cm and 50% effaced
A client with human immunodeficiency virus (HIV) infection has white lesions in the oral
cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish
and swallow. Which information is most important for the nurse to provide the client? -
ANSOral hygiene should be performed before the medication.
A client who is admitted with emphysema is having difficulty breathing. In which position
should the nurse place the client? - ANSSitting upright and forward with both arms supported
on an over the bed table
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ)
PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's
serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium
level? - ANSThe client's renal function has affected his potassium level.
A registered nurse (RN) delivers telehealth services to clients via electronic communication.
Which nursing action creates the greatest risk for professional liability and has the potential
for a malpractice lawsuit? - ANSSending medical records to health care providers via the
Internet
Which pathophysiologic response supports the contraindication for opioids, such as
morphine, in clients with increased intracranial pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated.
B.Higher doses of opioids are required when cerebral blood flow is reduced by an elevated
ICP.
C.Dysphoria from opioids contributes to altered levels of consciousness with an elevated
ICP.
D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP. -
ANSD
The greatest risk associated with opioids such as morphine (D) is respiratory depression that
causes an increase in Pco2, which increases ICP and masks the early signs of intracranial
bleeding in head injury. (A, B, and C) do not support the risks associated with opioid use in a
client with increased ICP.
The charge nurse of a medical surgical unit is alerted to an impending disaster requiring
implementation of the hospital's disaster plan. Specific facts about the nature of this disaster
,are not yet known. Which instruction should the charge nurse give to the other staff
members at this time?
A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
D.Continue with current assignments until more instructions are received. - ANSD
When faced with an impending disaster, hospital personnel may be alerted but should
continue with current client care assignments until further instructions are received (D).
Evacuation is typically a response of last resort that begins with clients who are most able to
ambulate (A). (B) is premature and is likely to increase the chaos if incoming casualties are
anticipated. (C) is poor utilization of personnel.
The nurse assesses a client while the UAP measures the client's vital signs. The client's vital
signs change suddenly, and the nurse determines that the client's condition is worsening.
The nurse is unsure of the client's resuscitative status and needs to check the client's
medical record for any advanced directives. Which action should the nurse implement?
A.Ask the UAP to check for the advanced directive while the nurse completes the
assessment.
B.Assign the UAP to complete the assessment while the nurse checks for the advanced
directive.
C.Check the medical record for the advanced directive and then complete the client
assessment.
D.Call for the charge nurse to check the advanced directive while continuing to assess the
client. - ANSD
Because the client's condition is worsening, the nurse should remain with the client and
continue the assessment while calling for help from the charge nurse to determine the
client's resuscitative status (D). (A and B) are tasks that must be completed by a nurse and
cannot be delegated to the UAP. (C) is contraindicated.
The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the nurse.
Which task is important for the nurse to perform, rather than the UAP?
A.Remove the client's nail polish and dentures.
B.Assist the client to the restroom to void.
C.Obtain the client's height and weight.
D.Offer the client emotional support. - ANSD
By using therapeutic techniques to offer support (D), the nurse can determine any client
concerns that need to be addressed. (A, B, and C) are all actions that can be performed by
the UAP under the supervision of the nurse.
Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel
(UAP) who usually works in labor and delivery and the newborn nursery is assigned to work
on the postoperative unit. Which client would be best for the charge nurse to assign to this
UAP?
A.An adolescent who was readmitted to the hospital because of a postoperative infection
, B.A woman with a new colostomy who requires discharge teaching
C.A woman who had a hip replacement and may be transferred to the home care unit
D.A man who had a cholecystectomy and currently has a nasogastric tube set to
intermittent suction - ANSC
The charge nurse will be responsible for providing a report to the home care unit if the
transfer occurs (A). The client is infected and an employee who works on an OB unit should
be assigned to clean cases in case the employee is required to return to the OB unit (B).
This requires the skills of a registered nurse (RN) to do discharge teaching and provide
emotional support (D). This may require skills beyond the level of this UAP.
A male client is admitted for observation after being hit on the head with a baseball bat. Six
hours after admission, the client attempts to crawl out of bed and asks the nurse why there
are so many bugs in his bed. His vital signs are stable, and the pulse oximeter reading is
98% on room air. Which intervention should the nurse perform first?
A.Administer oxygen per nasal cannula at 2 L/min.
B.Plan to check his vital signs again in 30 minutes.
C.Notify the health care provider of the change in mental status.
D.Ask the client why he thinks there are bugs in the bed. - ANSC
One of the earliest signs of increased intracranial pressure (ICP) is a change in mental
status (C). It is important to act early and quickly when symptoms of increased ICP occur.
Because his oxygen saturation is normal, the administration of oxygen (A) is not the top
priority. Vital signs should be monitored frequently (B), but the client's confusion should be
reported immediately. (D) is not a useful intervention.
The nurse is monitoring a client who is receiving bedside conscious sedation with midazolam
hydrochloride (Versed). In assessing the client, the nurse determines that the client has
slurred speech with diplopia. Based on this finding, what action should the nurse take?
A.Open the airway with a chin lift-head tilt maneuver.
B.Obtain a fingerstick glucose reading.
C.Administer flumazenil (Romazicon).
D.Continue to monitor the client. - ANSD
The desired level III in conscious sedation includes slurred speech, glazed eyes, and
marked diplopia. Because this is the desired outcome of the medication regimen, no action
is needed but continuing to monitor the client (D). The airway is open if the client is able to
talk (A). There are no signs of hypoglycemia (B). No reversal is necessary for the
benzodiazepine (Versed) without signs of oversedation, such as respiratory depression (C).
The nurse is assessing a client using the Snellen chart and determines that the client's visual
acuity is the same as in a previous examination, which was recorded as 20/100. When the
client asks the meaning of this, which information should the nurse provide?
A.This visual acuity result is five times worse that of a normal finding.
B.This line should be seen clearly when the client wears corrective lenses.
C.A client with normal vision can read at 100 feet what this client reads at 20 feet.
D.This client can see at 100 feet what a client with normal vision can see at 20 feet. - ANSC
