HESI RN EXIT Exam Questions and Answers PDF

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1. In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust? A) Food B) Warmth C) Security D) Comfort 2. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? A) "I cannot give this medication as it is written. I have no idea of what you mean." B) "Would you please clarify what you have written so I am sure I am reading it correctly?" C) "I am having difficulty reading your handwriting. It would save me time if you would be more careful." D) "Please print in the future so I do not have to spend extra time attempting to read your writing." 3. What is the most important consideration when teaching parents how to reduce risks in the home? A) Age and knowledge level of the parents B) Proximity to emergency services C) Number of children in the home D) Age of children in the home 4. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should A) Administer a placebo B) Encourage increased fluid intake C) Administer the prescribed analgesia D) Recommend relaxation exercises for pain control 5. While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention? A) Respiratory rate of 42 B) Lethargy for the past hour C) Apical pulse of 54 D) Coughing up copious secretions 6. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings? A) Lethargy B) Heat intolerance C) Diarrhea D) Skin eruptions 7. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse? A) "Do not worry. Epilepsy can be treated with medications." B) "The seizure may or may not mean your child has epilepsy." C) "Since this was the first convulsion, it may not happen again." D) "Long term treatment will prevent future seizures." 8. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies? A) Risk for injury B) Risk for knowledge deficit C) Altered thought process D) Disturbance in self-esteem 9. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? A) Hemoglobin level of 12 g/dI B) Pale mucosa of the eyelids and lips C) Hypoactivity D) A heart rate between 140 to 160 10.The nurse is caring for a client in hypertensive crisis in an intensive care unit.The priority assessment in the 1st hour of care is A) Heart rate B) Pedal pulses C) Lung sounds D) Pupil responses

11. Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient-controlled analgesia (PCA) with a pump? A) A young adult with a history of Down's syndrome B) A teenager who reads at a 4th grade level C) An elderly client with numerous arthritic nodules on the hands D) A preschooler with intermittent episodes of alertness 12. The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be A) Irritable and "colicky" with no attempts to pull to standing B) Alert, laughing and playing with a rattle, sitting with support C) Skin color dusky with poor skin turgor over abdomen D) Pale, thin arms and legs, uninterested in surroundings 13. As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss 14. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to A) Call the health care provider immediately B) Administer acetaminophen as ordered as this is normal at this time C) Send blood, urine and sputum for culture D) Increase the client's fluid intake 15.A client is admitted for 1st and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be A) Cover the areas with dry sterile dressings B) Assess for dyspnea or stridor C) Initiate intravenous therapy D) Administer pain medication 16. Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? A) I started my period and now my urine has turned bright red. B) I am an diabetic and today I have been going to the bathroom every hour. C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom. D) I went to the bathroom and my urine looked very red and it didn’t hurt when I went. 17. Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis? A) I noticed a little lump a little above the belly button. B) The baby seems hungry all the time. C) Mild vomiting that progressed to vomiting shooting across the room. D) Irritation and spitting up immediately after feedings. 18. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings? A) Decreased cardiac output B) Tissue hypoxia C) Cerebral edema D) Reduced oxygen saturation 19. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet A) High in carbohydrates and proteins B) Low in carbohydrates and proteins C) High in carbohydrates, low in proteins D) Low in carbohydrates, high in proteins

20. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant? A) Increased 10% in height B) 2 deciduous teeth C) Tripled the birth weight D) Head > chest circumference 21.A Hispanic client in the postpartum period refuses hospital food because it is cold. The best initial action by the nurse is to A) 1Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes B) Ask the client what foods are acceptable or bad C) Encourage her to eat for healing and strength D) Schedule the dietitian to meet with the client as soon as possible 22. The father of an 8 month-old infant asks the nurse if his infant's vocalizations are normal for his age. Which of the following would the nurse expect at this age? A) Cooing B) Imitation of sounds C) Throaty sounds D) Laughter 23. The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended? A) Seizures B) Withdrawal C) Craving D) Marked tolerance 24. Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner’s injuries by A) Seeking medical help for the victim's injuries B) Minimizing the episode and underestimating the victim’s injuries C) Contacting a close friend and asking for help D) Being very remorseful and assisting the victim with medical care 25. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse’s initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? A) "I have a sharp pain in my chest when I take a breath." B) "I have been coughing up foul-tasting, brown, thick sputum." C) "I have been sweating all day." D) "I feel hot off and on." 26. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal A) S3 ventricular gallop B) Apical click C) Systolic murmur D) Split S2 27. Which of these observations made by the nurse during an excretory urogram indicate a complicaton? A) The client complains of a salty taste in the mouth when the dye is injected B) The client’s entire body turns a bright red color C) The client states “I have a feeling of getting warm.” D) The client gags and complains “ I am getting sick.” 28. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? A) "The tube will drain fluid from your chest." B) "The tube will remove excess air from your chest." C) "The tube controls the amount of air that enters your chest." D) "The tube will seal the hole in your lung."

29. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? A) Blood urea nitrogen 50 mg/dl B) Hemoglobin of 10.3 mg/dl C) Venous blood pH 7.30 D) Serum potassium 6 mEq/L 30. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse’s immediate attention? A) Pallor B) Increased temperature C) Dyspnea D) Involuntary muscle spasms 31. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? A) Breath sounds can be heard bilaterally B) Mist is visible in the T-Piece C) Pulse oximetry of 88 D) Client is unable to speak 32. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? A) Drowsiness B) Complaint of nausea C) Pulse rate of 92 D) Restlessness 33. During the evaluation phase for a client, the nurse should focus on A) All finding of physical and psychosocial stressors of the client and in the family B) The client's status, progress toward goal achievement, and ongoing re-evaluation C) Setting short and long-term goals to insure continuity of care from hospital to home D) Select interventions that are measurable and achievable within selected timeframes 34. The school nurse suspects that a third grade child might have Attention Deficit Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should A) Observe the child's behavior on at least 2 occasions B) Consult with the teacher about how to control impulsivity C) Compile a history of behavior patterns and developmental accomplishments D) Compare the child's behavior with classic signs and symptoms 35. Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care? A) Measure head circumference B) Place in airborne isolation C) Provide passive range of motion D) Provide an over-the-crib protective top 36. A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values? A) Blood urea nitrogen B) Acid phosphatase C) Bilirubin D) Sedimentation rate 37. The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct? A) May drink as much milk as desired B) Can have milk mixed with other foods C) Will benefit from fat-free cow's milk D) Should be limited to 3-4 cups of milk daily

38. The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client’s behavior most likely indicates A) Neologisms B) Dissociation C) Flight of ideas D) Word salad 39. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age? A) Jumping rope B) Tying shoelaces C) Riding a tricycle D) Playing hopscotch 40. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is A) A transparent film dressing B) Wet dressing with debridement granules C) Wet to dry with hydrogen peroxide D) Moist saline dressing 41. The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!” What would be the most appropriate next action? A) Leave the room and return five minutes later and give the medicine B) Explain to the child that the medicine must be taken now C) Give the medication to the father and ask him to give it D) Mix the medication with ice cream or applesauce 42. A nurse is doing pre conceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome? A) "I understand that a glass of wine with dinner is healthy." B) "Beer is not really hard alcohol, so I guess I can drink some." C) "If I drink, my baby may be harmed before I know I am pregnant." D) "Drinking with meals reduces the effects of alcohol." 43. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? A) Increased blood pressure B) Increased heart rate C) Loss of pulse in the extremity D) Decreased urine output 44. A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? A) Have him drink several glasses of water B) Crede’ the bladder from the bottom to the top C) Assist him to stand by the side of the bed to void D) Wait 2 hours and have him try to void again 45. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A) Disconnect the client from the ventilator and use a manual resuscitation bag B) Perform a quick assessment of the client's condition C) Call the respiratory therapist for help D) Press the alarm re-set button on the ventilator 46. The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? A) "I can't lie in 1 position for more than thirty minutes." B) "I am allergic to shrimp." C) "I suffer from claustrophobia." D) "I developed a severe headache after a spinal tap."

47. The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? A) Hold the tube feeding and notify the provider B) Administer the tube feeding as scheduled C) Irrigate the tube with diet cola soda D) Apply intermittent suction to the feeding tube 48. To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must A) Apply suction for no more than 10 seconds B) Maintain sterile technique C) Lubricate 3 to 4 inches of the catheter tip D) Withdraw catheter in a circular motion 49. An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to A) Administer the medication in 2 separate injections B) Give the medication in the dorsal gluteal site C) Call to get a smaller volume ordered D) Check with pharmacy for a liquid form of the medication skip 50. The nurse receives an order to give a client iron by deep injection. The nurse knows that the reason for this route is to A) Enhance absorption of the medication B) Ensure that the entire dose of medication is given C) Provide more even distribution of the drug D) Prevent the drug from tissue irritation Skip 51. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? A) Diaphoresis with decreased urinary output B) Increased heart rate with increase respirations C) Improved respiratory status and increased urinary output D) Decreased chest pain and decreased blood pressure 52. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse’s best response? A) ”As you urinate more, you will need less medication to control fluid." B) ”You will have to take this medication for about a year." C) ”The medication must be continued so the fluid problem is controlled." D) ”Please talk to your health care provider about medications and treatments." 53. A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? A) Change in libido, breast enlargement B) Sore throat, fever C) Abdominal pain, nausea, diarrhea D) Dsypnea, nasal congestion 54. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child’s foot. Which action should the nurse implement first? A. Cleanse the foot with soap and water and apply an antibiotic ointment B. Provide teaching about the need for a tetanus booster within the next 72 hours. C. have the mother check the child's temperature q4h for the next 24 hours D. transfer the child to the emergency department to receive a gamma globulin injection 55. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences A. Bradycardia and constipation B. Lethargy and lack of appetite C. Muscle cramping and dry, flushed skin D. Palpitations and shortness of breath

56. A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? Obtain a list of medications taken for cardiac history 57. The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) A. Fluid shifts from intravascular to interstitial area due to decreased serum protein B. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen C. Increased circulating aldosterone levels that increase sodium and water retention 58. The nurse is auscultating a client’s heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies)? Murmur 59. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound? A) Transparent dressing B) Dry sterile dressing with antibiotic ointment C) Wet to dry dressing D) Occlusive moist dressing 60. A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child? A) Cartoon stickers B) Large wooden puzzle C) Blunt scissors and paper D) Beach ball 61. A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the A) Yang, the positive force that represents light, warmth, and fullness B) Yin, the negative force that represents darkness, cold, and emptiness C) Use of improper hot foods, herbs and plants D) A failure to keep life in balance with nature and others 62. A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response? A) "There is a probability of life-long complications." B) "Cystic fibrosis results in nutritional...