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HESI EXIT EXAM PART 3 QUESTIONS AND ANSWERS
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HESI EXIT EXAM PART 3 QUESTIONS AND ANSWERS
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HESI EXIT EXAM PART 3 QUESTIONS AND ANSWERSFollowing an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult
to arouse, and his respiration are slow and shallow. Which action should the nurse
implement? Select all that apply.
a. Prepare medication reversal agent
b. Check oxygen saturation level
c. Apply oxygen via nasal cannula
d. Initiate bag- valve mask ventilation.
e. Begin cardiopulmonary resuscitation - Answers-a. Prepare medication reversal agent
b. Check oxygen saturation level
c. Apply oxygen via nasal cannula
Rationale: Sedation, given during the procedure may need to be reverse if the client
does not easily wake up. Oxygen saturation level should be asses, and oxygen applied
to support respiratory effort and oxygenation. The client is still breathing so the bag-
valve mask ventilation and CPR are not necessary.
Which intervention should the nurse implement during the administration of vesicant
chemotherapeutic agent via an IV site in the client's arm?
a. Explain the temporary burning of the IV site may occur.
b. Assess IV site frequently for signs of extravasation
c. Apply a topical anesthetic of the infusion site for burning
d. Monitor capillary refill distal to the infusion site. - Answers-Assess IV site frequently
for signs of extravasation
Rationale: Infiltration of a vesicant can cause severe tissue damage and necrosis, so
the IV site should be assessed regularly for extravasation (B) of the chemotherapeutic
agent. The client should be instructed to report any discomfort at the site (A). If pain and
burning occur, the IV should be stopped and C is not indicated. Peripheral pulses, not
D, provide the best assessment of perfusion distal to the infusion should the drug
extravasate or infiltrate.
When development a teaching plan for a client newly diagnosed type 1 diabetes, the
nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis
(DKA), which action should the nurse instruct the client to implement if this sign of DKA
occur?
a. Resume normal physical activity
b. Drink electrolyte fluid replacement
c. Give a dose of regular insulin per sliding scale
d. Measure urinary output over 24 hours. - Answers-Give a dose of regular insulin per
sliding scale
,Rationale: As hyperglycemia persist, ketone body become a fuel source, and the client
manifest early signs of DKA that include excessive thirst, frequent urination, headache,
nausea and vomiting. Which result in dehydration and loss of electrolyte. The client
should determine fingerstick glucose level and self-administer a dose of regular insulin
per sliding scale.
The nurse is teaching a group of clients with rheumatoid arthritis about the need to
modify daily activities. Which goal should the nurse emphasize?
a. Protect joint function
b. Improve circulation
c. Control tremors
d. Increase weight bearing. - Answers-a. Protect joint function
Rationale: Primary goal in the management of rheumatoid arthritis is to protect and
maintain joint function.
An adult client experiences a gasoline tank fire when riding a motorcycle and is
admitted to the emergency department (ED) with full thickness burns to all surfaces of
both lower extremities. What percentage of body surface area should the nurse
document in the electronic medical record (EMR)? - Answers-36%
(1 total leg front/back = 18, 1 total arm front/back = 9, torso = 18, back = 18, head = 9,
pubic = 1 = 100%)
Rational: according to the rule of nines, the anterior and posterior surfaces of one lower
extremity is designated as 18 %of total body surface area (TBSA), so both extremities
equal 36% TBSA, other options are incorrect.
A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates
that the medication is having the desired effect
a. Decrease in serum T4 levels
b. Increase in blood pressure
c. Decrease in pulse rate
d. Goiter no longer palpable. - Answers-Decrease in pulse rate
Rationale: Beta blockers such as propranolol help control the symptoms of
hyperthyroidism, such as palpitations or tachycardia, but do not alter thyroid hormone
levels, B is not a desired effect in hyperthyroidism. Beta blocker do not impact the
presence of a goiter.
The nurse is planning preoperative teaching plan of a 12-years old child who is
scheduled for surgery. To help reduce the child anxiety, which action is the best for the
nurse to implement?
,a. Give the child syringes or hospital mask to play it at home prior to hospitalization.
b. Include the child in pay therapy with children who are hospitalized for similar surgery
.c. Provide a family tour of the preoperative unit one week before the surgery is
scheduled.
d. Provide doll an equipment to re-enact feeling associated with painful procedures -
Answers-Provide a family tour of the preoperative unit one week before the surgery is
scheduled
Rationale: School age children gain satisfaction from exploring and manipulating their
environment, thinking about objectives, situations and events, and making judgments
based on what they reason. A tour of the unit allows the child to see the hospital
environment and reinforce explanation and conceptual thinking.
An older male client with type 2 diabetes mellitus reports that has experiences legs pain
when walking short distances, and that the pain is relieved by rest. Which client
behavior indicates an understanding of healthcare teaching to promote more effective
arterial circulation?
a. Consistently applies TED hose before getting dressed in the morning.
b. Frequently elevated legs thorough the day.
c. Inspect the leg frequently for any irritation or skin breakdown
d. Completely stop cigarette/ cigar smoking. - Answers-Completely stop cigarette/ cigar
smoking
Rationale: Stopping cigarette smoking helps to decrease vasoconstriction and improve
arterial circulation to the extremity.
A community health nurse is concerned about the spread of communicable diseases
among migrant farm workers in a rural community. What action should the nurse take to
promote the success of a healthcare program designed to address this problem?
a. Conduct face to face prevention education group session is Spanish
b. Offer low literacy material that explain respiratory hygiene and handwashing
techniques
c. Establish trust with community leaders and respect cultural and family values.
, d. Provide public services announcements advising those who aril o seek prompt
medical attention. - Answers-c. Establish trust with community leaders and respect
cultural and family values.
The nurse performs a prescribed neurological check at the beginning of the shift on a
client who was admitted to the hospital with a subarachnoid brain attack (stroke). The
client's Glasgow Coma Scale (GCS) score is 9. What information is most important for
the nurse to determine?
a. When the client's stroke symptoms started
b. If the client is oriented to time
c. The client's previous GCS score.
d. The client's blood pressure and respiration rate. - Answers-c. The client's previous
GCS score.Rationale: The normal GCS is 15, and it is most important for the nurse
determine if this abnormal score is a sign of improvement or deterioration in the client's
conditions. A is irrelevant. B is part of the GCS. The classic vital signs in late or sudden
increasing ICP are Cushing's triad (widening pulse pressure, bradycardia with full,
bounding pulse, and irregular respirations) Additional vital signs and trending of values
are needed to evaluate the current finding(D) and C is a more sensitive, consistent
evaluation
The charge nurse in a critical care unit is reviewing clients' conditions to determine who
is stable enough to be transferred. Which client status report indicates readiness for
transfer from the critical care unit to a medical unit?
a. Pulmonary embolus with an intravenous heparin infusion and new onset hematuria
b. Myocardial infarction with sinus bradycardia and multiple ectopic beats
c. Adult respiratory distress syndrome with pulse oximetry of 85% saturation.
d. Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation - Answers-
d. Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation
Rationale: A slight bilirubin elevation and anemia are expected finding in a stable client
with chronic liver failure who should be transferred to a less-acute medical unit.
Based on principles of asepsis, the nurse should consider which circumstance to be
sterile?
a. One inch- border around the edge of the sterile field set up in the operating room
b. A wrapped unopened, sterile 4x4 gauze placed on a damp table top.
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