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EXIT HESI - Comprehensive PN Exam A Practice Questions
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A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the baby sucks for a few minutes?" Which information should the nurse provide? A.This feeling occurs during feeding with a breast infection. B.This sensation occurs as breast milk moves to...

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  • September 12, 2024
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  • 2024/2025
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EXIT HESI - Comprehensive PN Exam A
Practice Questions
A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the baby sucks
for a few minutes?" Which information should the nurse provide?

A.This feeling occurs during feeding with a breast infection.
B.This sensation occurs as breast milk moves to the nipple.
C.The baby does not have good latch-on.
D.The infant is not positioned correctly. - Correct Answer B
When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they feel a tingling sensation
in their nipples (B) when let-down occurs. (A, C, and D) provide inaccurate information.

A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic complaining of a
pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first? - Correct
Answer Check the client's blood pressure.

A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the nurse
implement? - Correct Answer Ask about scrotal pain or blood in the semen.

A 77-year-old female client states that she has never been so large around the waist and that she has frequent
periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which information should
the nurse provide to this client? - Correct Answer With age, more fatty tissue develops in the abdomen and
decreased intestinal movement can cause constipation.

A child is having a generalized tonic-clonic seizure. Which action should the nurse take?

A.Move objects out of the child's immediate area.
B.Quickly slip soft restraints on the child's wrists.
C.Insert a padded tongue blade between the teeth.
D.Place in the recovery position before going for help. - Correct Answer A
The first priority during a seizure is to provide a safe environment, so the nurse should clear the area (A) to reduce
the risk of trauma. The child should not be restrained (B) because this may cause more trauma. Objects should not
be placed in the child's mouth (C) because it may pose a choking hazard. Although (D) should be implemented after
the seizure, the nurse should not leave the child during a seizure to get help.

A child with nephrotic syndrome is receiving prednisone (Deltasone). Which choice of breakfast foods at a fast food
restaurant indicates that the mother understands the dietary guidelines necessary for her child? - Correct Answer
Toasted oat cereal and low-fat milk

A client has been on a mechanical ventilator for several days. What should the nurse use to document and record
this client's respirations? - Correct Answer The ventilator setting for respiratory rate and the client-initiated
respirations

A client has been receiving levofloxacin (Levaquin), 500 mg IV piggyback q24h for 7 days. The UAP reports to the
nurse that the client has had three loose foul-smelling stools this morning. Which intervention is most important for
the nurse to implement? - Correct Answer Obtain a stool specimen for culture and sensitivity.

A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this client likely to be
exhibiting?

A.Hyperexcitability of reflexes
B.Hyperextension of the head and back
C.Inability to flex the chin to the chest
D.Lateral facial paralysis - Correct Answer C
Nuchal rigidity (neck stiffness) is a characteristic of meningeal irritation and is elicited by attempting to flex the neck
and place the chin to the chest (C). Although (A, B, and D) may occur in meningitis, (A) describes exaggerated spinal

, nerve reflex responses, (B) describes opisthotonus, and (D) may be related to cranial nerve pathology of the
trigeminal nerve.

A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and sleeping
difficulties. While talking about the death of a friend, the client states, "I can't believe this happened." Which statement
by the nurse is most therapeutic? - Correct Answer "Tell me more about how you're feeling."

A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse provide? -
Correct Answer Save the next urine sample.

A client tells the nurse that he is suffering from insomnia. Which information is most important for the nurse to obtain?
- Correct Answer The client's usual sleeping pattern

A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the
client? - Correct Answer Sitting upright and forward with both arms supported on an over the bed table

A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy with placement of
ventilating tubes. Which response by the client indicates that further teaching is necessary?

A."I will avoid coughing, sneezing, and forceful nose blowing."
B."Swimming can begin on the tenth postoperative day."
C."Any mild discomfort can be managed with acetaminophen."
D."Drainage from my ears is expected after the surgery." - Correct Answer B
The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure and drain fluid collection from
the middle ear. The tube's patency allows air and water to enter the middle ear, so the client should be reeducated if
the client swims (B) or allows water to enter the external ear. (A, C, and D) reflect correct responses.

A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent discharge. Which nursing
intervention is most important in reducing the client's stress associated with repeated hospitalization? - Correct
Answer Encourage as much independence in decision making as possible.

A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is initiated. Which complication is
important for the nurse to monitor the client for at this time? - Correct Answer Hypotension

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? - Correct Answer The client's renal function has affected his
potassium level.

A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the need for dialysis. Which
information should the nurse provide the client prior to the test?

A.Failure to collect all urine specimens during the period of the study will invalidate the test.
B.Blood is collected to measure the amount of creatinine and determine the glomerular filtration rate (GFR).
C.Dialysis is started when the GFR is lower than 5 mL/min.
D.Discard the first voiding, and record the time and amount of urine of each voiding for 24 hours. - Correct Answer A
Glomerulonephritis damages the renal glomeruli and affects the kidney's ability to clear serum creatinine into the
urine. Creatinine clearance is a 24-hour urine specimen test, so all urine should be collected during the period of the
study or the results are inaccurate (A). As renal function decreases, the creatinine level will decrease in the urine (B).
Dialysis is usually started when the GFR is 12 mL/min (C). There is no need to record the frequency and amount of
each voiding (D) during the time span of urine collection.

A client with hemiparesis needs assistance transferring from the bed to the wheelchair. The nurse assists the client to
a sitting position on the side of the bed. Which action should the nurse implement next? - Correct Answer Allow the
client to sit on the side of the bed for a few minutes before transferring.

A client with hemiplegia who is on bed rest is turned to the supine position, and the nurse determines that the client's
hips are externally rotated. Which intervention is most important for the nurse to implement?

A.Request a prescription for a bed board to provide increased back support.
B.Reposition the client so that both feet are supported by the bed board.
C.Move the trapeze bar to allow the client to pull with the upper extremities.

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