2019 HESI EXIT V2

1.       The nurse knows that which statement by the mother indicates that the mother

understands safety precautions with her four month-old infant and her 4 year-old child?

A) “I strap the infant car seat on the front seat to face backwards.” B) “I place my infant in the middle of the living room floor on a blanket to play with my

4 year old while I make supper in the kitchen.”

C)      “My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air

while the four year old naps on the sofa.”

D)      “I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper.”

The correct answer is D: “I have the four year-old hold and help feed the four month-old a bottle in the kitchen

2.       Upon completing the admission documents, the nurse learns that the 87 year-old client

does not have an advance directive. What action should the nurse take?

A)   Record the information on the chart

B)   Give information about advance directives

C)   Assume that this client wishes a full code

D)   Refer this issue to the unit secretary

The correct answer is B: Give information about advance directives 3. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after

the immunization was given, the client complains of itchy and watery eyes, increased

anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to

A)   Maintain the airway

B)   Administer epinephrine 1:1000 as ordered

C)   Monitor for hypotension with shock

D)   Administer diphenhydramine as ordered

The correct answer is B: Administer epinephrine 1:1000 as ordered

.

4. Which of these children at the site of a disaster at a child day care center would the triage nurse put in the “treat last” category?

A)      An infant with intermittent bulging anterior fontanel between crying episodes

B)      A toddler with severe deep abrasions over 98% of the body C) A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture

D) A school-age child with singed eyebrows and hair on the arms The correct answer is B: A toddler with severe deep abrasions over 98% of the body .

5. When admitting a client to an acute care facility, an identification bracelet is sent up

with the admission form. In the event these do not match, the nurse’s best action is to

A)  Change whichever item is incorrect to the correct information

B)  Use the bracelet and admission form until a replacement is supplied

C)  Notify the admissions office and wait to apply the bracelet

D)  Make a corrected identification bracelet for the client The correct answer is C: notify the admissions office and wait to apply the bracelet

6. The nurse is having difficulty reading the health care provider’s written order that was written right before the shift change. What action should be taken?

A)  Leave the order for the oncoming staff to follow-up

B)  Contact the charge nurse for an interpretation

C)  Ask the pharmacy for assistance in the interpretation D) Call the provider for clarification

The correct answer is D: Call the provider for clarification 7. An adult client is found to be unresponsive on morning rounds. After checking for

responsiveness and calling for help, the next action that should be taken by the nurse is to:

A)   check the carotid pulse

B)   deliver 5 abdominal thrusts

C)   give 2 rescue breaths

D)   open the client’s airway

The correct answer is D: open the client'’s airway

8. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers

that 800 ml has been infused after 4 hours. What is the priority nursing action?

A)   Ask the client if there are any breathing problems

B)   Have the client void as much as possible

C)   Check the vital signs

D)   Auscultate the lungs

The correct answer is D: Auscultate the lungs

9. Following change-of-shift report on an orthopedic unit, which client should the nurse see first?

A)  16 year-old who had an open reduction of a fractured wrist 10 hours ago

B)  20 year-old in skeletal traction for 2 weeks since a motor cycle accident

C)  72 year-old recovering from surgery after a hip replacement

2 hours ago

D) 75 year-old who is in skin traction prior to planned hip pinning surgery. The correct answer is C: 72 year-old recovering from surgery after a hip replacement 2 hours ago

10. A nurse observes a family member administer a rectal suppository by having the

client lie on the left side for the administration. The family member pushed the

suppository until the finger went up to the second knuckle. After

10 minutes the client

was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?

A)   Why don’t we now have the client turn back to the left side.

B)   That was done correctly. Did you have any problems with the insertion?

C)   Let’s check to see if the suppository is in far enough.

D)   Did you feel any stool in the intestinal tract?

The correct answer is B: That was done correctly. Did you have any problems with the insertion?

11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has

died. Which type of precautions is the appropriate type to use when performing postmortem care? A) airborne precautions

B)   droplet precautions

C)   contact precautions

D)   compromised host precautions

The correct answer is C: contact precautions

12. The nurse is reviewing with a client how to collect a clean catch urine specimen.

Which sequence is appropriate teaching?

A)   Void a little, clean the meatus, then collect specimen

B)   clean the meatus, begin voiding, then catch urine stream

C)   Clean the meatus, then urinate into container

D)   Void continuously and catch some of the urine

The correct answer is B: clean the meatus, begin voiding, then catch urine stream

13. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40 mg every

day. Which of these foods would the nurse reinforce for the client to eat at least daily? A) spaghetti

B)   watermelon

C)   chicken

D)   tomatoes

The correct answer is B: watermelon

14. A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take?

A)   Look up the policy on needle sticks

B)   Contact employee health services

C)   Immediately wash the hands with vigor

D)   Notify the supervisor and risk management

The correct answer is C: Immediately wash the hands with vigor 15. As the nurse observes the student nurse during the

administration of a narcotic

analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? A) Ask the student: “What did you forget to do?”

B)  Stop. Tell me why aspiration is needed.

C)  Loudly state: “You forgot to aspirate.”

D)  Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.” The correct answer is D: Walk up and whisper in the student’s ear “Stop.

Aspirate.

Then inject.”

16. A client with Guillain Barre is in a non responsive state, yet vital signs are stable and

breathing is independent. What should the nurse document to most accurately describe the client’s condition?

A)   Comatose, breathing unlabored

B)   Glascow Coma Scale 8, respirations regular

C)   Appears to be sleeping, vital signs stable

D)   Glascow Coma Scale 13, no ventilator required

The correct answer is B: Glascow Coma Scale 8, respirations regular

17. A client enters the emergency department unconscious via ambulance from the

client’s work place. What document should be given priority to guide the direction of care for this client?

A)  The statement of client rights and the client self determination act

B)  Orders written by the health care provider

C)  A notarized original of advance directives brought in by the partner

D)  The clinical pathway protocol of the agency and the emergency department

The correct answer is C: A notarized original of advance directives brought in by the partner

18. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive

personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager?

A)      An admission at the change of shifts with atrial fibrillation and heart failure - PN

B)      Client who had a major stroke 6 days ago - PN nursing student C) A child with burns who has packed cells and albumin IV running - charge nurse

D) An elderly client who had a myocardial infarction a week ago - UAP The correct answer is A: An admission at the change of shifts with atrial fibrillation and heart failure - PN

19. A mother brings her 3 month-old into the clinic, complaining that the child seems to

be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment?

A)   Increased temperature and lethargy

B)   Restlessness and increased mucus production

C)   Increased sleeping and listlessness

D)   Diarrhea and poor skin turgor

The correct answer is B: Restlessness and increased mucus production

20. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis?

A)  “The child has been listless and has lost weight.”

B)  “The urine is dark yellow and small in amounts.”

C)  “Clothes are becoming tighter across her abdomen.”

D)  “We notice muscle weakness and some unsteadiness.” The correct answer is C: “Clothes are becoming tighter across her abdomen.”

21. A 16 year-old enters the emergency department. The triage nurse identifies that this

teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse?

A)      Ask the teenager to wait until a parent or legal guardian can be contacted

B)      Withhold treatment until telephone consent can be obtained from the partner

C)      Refer the teenager to a community pediatric hospital emergency department

D)      Proceed with the triage process in the same manner as any adult client The correct answer is D: Proceed with the triage process in the same manner as any adult client

22. A newly admitted elderly client is severely dehydrated. When planning care for this

client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?

A)   Converse with the client to determine if the mucous membranes are impaired

B)   Report hourly outputs of less than 30 ml/hr

C)   Monitor client’s ability for movement in the bed

D)   Check skin turgor every 4 hours

The correct answer is B: Report output of less than 30 ml/hr 23. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever.

Which statement by the parent would cause the nurse to suspect an association with this disease?

A)   Our child had chickenpox 6 months ago.

B)   Strep throat went through all the children at the day care last month.

C)   Both ears were infected over 3 months age.

D)   Last week both feet had a fungal skin infection.

The correct answer is B: Strep throat went through all the children at the day care last month.

24. A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a

reluctance to interact with the client. The next action by the nurse should be to

A)  Discuss the feeling of reluctance with an objective peer or supervisor

B)  Limit contacts with the client to avoid reinforcement of the manipulative behavior

C)  Confront the client about the negative effects of behaviors on other clients and staff

D)  Develop a behavior modification plan that will promote more functional behavior

The correct answer is A: Discuss the feeling of reluctance with an objective peer or supervisor

25. A client is being treated for paranoid schizophrenia. When the client became loud and

boisterous, the nurse immediately placed him in seclusion as a precautionary measure.

The client willingly complied. The nurse’s action

A)  May result in charges of unlawful seclusion and restraint

B)  Leaves the nurse vulnerable for charges of assault and battery

C)  Was appropriate in view of the client’s history of violence

D)  Was necessary to maintain the therapeutic milieu of the unit The correct answer is A: May result in charges of unlawful seclusion and restraint

26. A client has been admitted to the Coronary Care Unit with a myocardial infarction.

Which nursing diagnosis should have priority?

A)   Pain related to ischemia

B)   Risk for altered elimination: constipation

C)   Risk for complication: dysrhythmias

D)   Anxiety related to pain

The correct answer is A: Pain related to ischemia

27. The provisions of the law for the Americans with Disabilities Act require nurse managers to

A)  Maintain an environment free from associated hazards

B)  Provide reasonable accommodations for disabled individuals

C)  Make all necessary accommodations for disabled individuals D) Consider both mental and physical disabilities

The correct answer is B: Provide reasonable accommodations for disabled individuals

28. A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as

prescribed. Which client statement s from the assessment data is likely to explain his noncompliance?

A)   “I have problems with diarrhea.”

B)   “I have difficulty falling asleep.”

C)   “I have diminished sexual function.”

D)   “I often feel jittery.”

The correct answer is C: “I have diminished sexual function.” 29. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours

ago. Which statement from the mother indicates that teaching has been inadequate?

A)      ”I will keep the cast for the next day uncovered to prevent burning of the skin.”

B)      ”I can apply an ice pack over the area to relieve itching inside the cast.”

C)      ”The cast should be propped on at least 2 pillows when my child is lying down."

D)      ”I think I remember that standing cannot be done until after 72 hours." The correct answer is D: “I think I remember that standing cannot be done until after 72 hours.”

30. Which statement best describes time management strategies applied to the role of a nurse manager?

A)  Schedule staff efficiently to cover the needs on the managed unit

B)  Assume a fair share of direct client care as a role model

C)  Set daily goals with a prioritization of the work

D)  Delegate tasks to reduce work load associated with direct care and meetings

The correct answer is C: Set daily goals with a prioritization of the work

31. The pediatric clinic nurse examines a toddler with a tentative diagnosis of

neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these? A) Lymphedema and nerve palsy

B)   Hearing loss and ataxia

C)   Headaches and vomiting

D)   Abdominal mass and weakness

The correct answer is D: Abdominal mass and weakness

32. A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching?

A)   “I will only have to wear this for 6 months.”

B)   “I should inspect my skin daily.”

C)   “The brace will be worn day and night.”

D)   “I can take it off when I shower.”

The correct answer is A: “I will only have to wear this for 6 months.” 33. The nurse manager has been using a decentralized block scheduling plan to staff the

nursing unit. However, staff have asked for many changes and exceptions to the schedule

over the past few months. The manager considers self scheduling knowing that this method will

A)  Improve the quality of care

B)  Decrease staff turnover

C)  Minimize the amount of overtime payouts D) Improve team morale

The correct answer is D: Improve team morale

34. A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?

A)   Diffuse expiratory wheezing

B)   Loose, productive cough

C)   No relief from inhalant

D)   Fever and chills

The correct answer is A: Diffuse expiratory wheezing

35. The nurse manager hears a health care provider loudly criticize one of the staff nurses

within the hearing of others. The employee does not respond to the health care provider’s

complaints. The nurse manager’s next action should be to A) Walk up to the health care provider and quietly state: “Stop this unacceptable

behavior.”

B) Allow the staff nurse to handle this situation without interference C) Notify the of the other administrative persons of a breech of professional conduct

D) Request an immediate private meeting with the health care provider and staff nurse

The correct answer is D: Request an immediate private meeting with the health care provider and staff nurse

36. A client is admitted to a voluntary hospital mental health unit due to suicidal ideation.

The client has been on the unit for 2 days and now states “I demand to be released now!”

The appropriate action is for the nurse to

A)  You cannot be released because you are still suicidal.

B)  You can be released only if you sign a no suicide contract.

C)  Let’s discuss your decision to leave and then we can prepare you for discharge.

D)  You have a right to sign out as soon as we get an order from the health care provider’s discharge order.

The correct answer is C: Let’s discuss your decision to leave and then we can prepare you for discharge.

37. A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition?

A)   Dyspnea

B)   Heart murmur

C)   Macular rash

D)   Hemorrhage

The correct answer is B: Heart murmur Large, soft, rapidly developing vegetations attach to the heart valves.

38. A nurse admits a premature infant who has respiratory distress syndrome. In planning

care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant’s inability to

A)   Stabilize thermoregulation

B)   Maintain alveolar surface tension

C)   Begin normal pulmonary blood flow

D)   Regulate intra cardiac pressure

The correct answer is B: Maintain alveolar surface tension 39. An 18 year-old client is admitted to intensive care from the emergency room

following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse’s priority assessment should be

A)   Response to stimuli

B)   Bladder control

C)   Respiratory function

D)   Muscle weakness

The correct answer is C: Respiratory function

40. The nurse is caring for a client who was successfully resuscitated from a pulseless

dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care? A) Hourly urine output

B)   White blood count

C)   Blood glucose every 4 hours

D)   Temperature every 2 hours

The correct answer is A: Hourly urine output

41. The charge nurse on the night shift at an urgent care center has to deal with admitting

clients of a higher acuity than usual because of a large fire in the area. Which style of

leadership and decision-making would be best in this circumstance?

A)   Assume a decision-making role

B)   Seek input from staff

C)   Use a non-directive approach

D)   Shared decision-making with others

The correct answer is A: Assume a decision making role

42. The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?

A)  Metabolic acidosis

B)  Metabolic alkalosis

C)  Some increase in the serum hemoglobin D) A little decrease in the serum potassium The correct answer is B:

Metabolic alkalosis

43. Which activity can the RN ask an unlicensed assistive personnel (UAP) to perform?

A)  Take a history on a newly admitted client

B)  Adjust the rate of a gastric tube feeding

C)  Check the blood pressure of a 2 hours post operative client D) Check on a client receiving chemotherapy

The correct answer is C: Check the blood pressure of a 2 hours post operative client

44. A child is injured on the school playground and appears to have a fractured leg. The

first action the school nurse should take is A) Call for emergency transport to the hospital

B)   Immobilize the limb and joints above and below the injury

C)   Assess the child and the extent of the injury

D)   Apply cold compresses to the injured area

The correct answer is C: Assess the child and the extent of the injury

45. When interviewing the parents of a child with asthma, it is most important to gather what information about the child’s environment?

A)   Household pets

B)   New furniture

C)   Lead based paint

D)   Plants such as cactus