HESI RN EXIT Exam Questions and Verified Answers 2024 Part 2

The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to

A) Exercise doing weight bearing activities

B) Exercise to reduce weight

C) Avoid exercise activities that increase the risk of fracture D) Exercise to strengthen muscles and thereby protect bones

The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?

A) Cheese sandwich with a glass of 2% milk

B) Sliced turkey sandwich and canned pineapple

C) Cheeseburger and baked potato

D) Mushroom pizza and ice cream

Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol?

A) All 4 side rails up, wheels locked, bed closest to door

B) Lower side rails up, bed facing doorway

C) Knees bent, head slightly elevated, bed in lowest position

D) Bed in lowest position, wheels locked, place bed against wall

The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group?

A) Bulimia

B) Anorexia

C) Obesity

D) Malnutrition

At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for me." The nurse should

A) Invite the client to join the exercise group

B) Tell the client you will call someone to come for her

C) Give the client simple information about what she will be doing

D) Firmly direct the client to her assigned group activity

A victim of domestic violence states to the nurse, "If only I could change and be how my companion wants me to be, I know things would be different." Which would be the best response by the nurse?

A) "The violence is temporarily caused by unusual circumstances, don't stop hoping for a change.

B) Perhaps, if you understood the need to abuse, you could stop the violence.

C) "No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?"

D) "Batterers lose self-control because of their own internal reasons, not because of what their

partner did or did not do."

A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation?

A) Degeneration of the alveoli

B) Chronic broncho constriction of the large airways

C) Lung remodeling and permanent changes in lung function

D) Frequent pneumonia

A mother wants to switch her 9 month-old infant from an iron fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse?

A) Change the baby to whole milk

B) Add chocolate syrup to the bottle

C) Continue with the present formula

D) Offer fruit juice frequently

Privacy and confidentiality of all client information is legally protected. In which of

these situations would the nurse make an exception to this practice?

A) When a family member offers information about their loved one

B) When the client threatens self-harm and harm to others

C) When the health care provider decides the family has a right to know the client's diagnosis

D) When a visitor insists that the visitor has been given permission by the client

The nurse is caring for a client who is in the late stage of multiple myeloma. Which of

the following should be included in the plan of care?

A) Monitor for hyperkalemia

B) Place in protective isolation

C) Precautions with position changes

D) Administer diuretics as ordered

The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment?

A) Activity intolerance caused by fatigue related to chronic tissue hypoxia

B) Impaired mobility related to chronic obstructive pulmonary disease

C) Self-care deficit caused by fatigue related to dyspnea

D) Ineffective airway clearance related to increased bronchial secretions

The nurse admits a client newly diagnosed with hypertension. What is the best

method for assessing the blood pressure?

A) Standing and sitting

B) In both arms

C) After exercising

D) Supine position

The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group?

A) Aerobic exercise classes

B) Transportation for shopping trips

C) Reminiscence groups

D) Regularly scheduled social activities

Post-procedure nursing interventions for electroconvulsive therapy include

A) Applying hard restraints if seizure occurs

B) Expecting client to sleep for 4 to 6 hours

C) Remaining with client until oriented

D) Expecting long-term memory loss

The nurse assesses delayed gross motor development in a 3 year-old child. The

inability of the child to do which action confirms this finding?

A) Stand on 1 foot

B) Catch a ball

C) Skip on alternate feet

D) Ride a bicycle

The mother of a 15 month-old child asks the nurse to explain her child's lab results

and how they show her child has iron deficiency anemia. The nurse's best response is

A) Although the results are here, your doctor will explain them later.

B) Your child has less red blood cells that carry oxygen.

C) "The blood cells that carry nutrients to the cells are too large."

D) "There are not enough blood cells in your child's circulation."

In a child with suspected coarctation of the aorta, the nurse would expect to find

A) Strong pedal pulses

B) Diminishing carotid pulses

C) Normal femoral pulses

D) Bounding pulses in the arms

At the day treatment center a client diagnosed with Schizophrenia - Paranoid Type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates

A) Feelings of increasing anxiety related to paranoia

B) Social isolation related to altered thought processes

C) Sensory perceptual alteration related to withdrawal from environment

D) Impaired verbal communication related to impaired judgment

A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0- to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to

A) Ask the client about the refusal of certain pain medications

B) Talk with the client's family about the situation

C) Report the situation to the health care provider

D) Document the situation in the notes

What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?

A) Presence of blood in stools

B) Oozing liquid stool

C) Continuous rumbling flatulence

D) Absence of bowel movements

A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to

A) Have the client identify coping methods

B) Get the description of the location and intensity of the pain

C) Accept the client's report of pain

D) Determine the client's status of pain

An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be

A) Assess the severity and location of the pain

B) Obtain an order for an analgesic

C) Reassure him that this is not unusual for his age

D) Encourage him to increase his activity

A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that:

A) Visitors must wear a mask and a gown

B) There are no special requirements for visitors of clients on contact precautions

C) Visitors should wash their hands before and after touching the client

D) Visitors

A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first?

A) Institute seizure precautions

B) Monitor neurologic status every hour

C) Place in respiratory/secretion precautions

D) Cefotaxime IV 50 mg/kg/day divided q6h

Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?

A) Sensory perceptual alterations related to decreased vision

B) Alteration in mobility related to fatigue

C) Impaired gas exchange related to retained secretions

D) Altered patterns of urinary elimination related to nocturia

A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these?

A) Apply appropriate signs outside and inside the room

B) Apply a mask with a shield if there is a risk of fluid splash C) Wear a gown to change soiled linens from incontinence

D) Have gloves on while handling bedpans with feces

Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours?

A) An infant with a positive culture of stool for Shigella

B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear

C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii

D) A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles on an erythematous base that appear on the skin

A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client?

A) Reverse

B) Airborne

C) Standard precautions

D) Contact

The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements?

A) "The treatment requires reapplication in 8 to 10 days."

B) "Bedding and clothing can be boiled or steamed."

C) Children are not to share hats, scarves and combs.

D) Nit combs are necessary to comb out nits.

During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches?

A) Wash hands thoroughly before and after client contact

B) Wear gloves when in contact with body secretions

C) Double glove when in contact with feces or vomitus

D) Wear gloves when disposing of contaminated linens

A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes?

A) Grilled chicken sandwich and skim milk

B) Roast beef, mashed potatoes, and green beans

C) Peanut butter sandwich, banana, and iced tea

D) Barbecue beef, baked beans, and cole slaw

After talking with her partner, a client voluntarily admitted herself to the substance abuse unit. After the second day on the unit the client states to the nurse, "My husband told me to get treatment or he would divorce me. I don't believe I really need treatment but I don't want my husband to leave me." Which response by the nurse would assist the client?

A) "In early recovery, it's quite common to have mixed feelings, but unmotivated people can't get well."

B) "In early recovery, it's quite common to have mixed feelings, but I didn't know you had been pressured to come."

C) "In early recovery it's quite common to have mixed feelings, perhaps it would be best to seek treatment on an out client bases. "

D) " In early recovery, it's quite common to have mixed feelings. Let's discuss the benefits of sobriety for you."

A neonate born 12 hours ago to a methadone maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passes loose, watery stool. Which of these is a nursing priority?

A) Hold the infant at frequent intervals.

B) Assess for neonatal withdrawal syndrome

C) Offer fluids to prevent dehydration

D) Administer paregoric to stop diarrhea

The nurse is caring for a post myocardial infarction client in an intensive care unit. It is noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This change is most likely due to

A) Dehydration

B) Diminished blood volume

C) Decreased cardiac output

D) Renal failure

The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is

A) Pain

B) Impaired gas exchange

C) Cardiac output altered: decreased

D) Fluid volume excess

The nurse is performing a developmental assessment on an 8 month-old. Which finding should be reported to the health care provider?

A) Lifts head from the prone position

B) Rolls from abdomen to back

C) Responds to parents' voices

D) Falls forward when sitting

A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly experiences torticollis and involuntary spastic muscle movement. In addition to administering the ordered anticholinergic drug, what other measure should the nurse implement?

A) Have respiratory support equipment available

B) Immediately place her in the seclusion room

C) Assess the client for anxiety and agitation

D) Administer PRN dose of IM antipsychotic medication

The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first

A) Assess the client's airway

B) Call for help

C) Establish that the client is unresponsive

D) See if anyone saw the client fall

The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to

A) Check for subcutaneous emphysema in the upper torso

B) Reposition the client to a position of comfort

C) Call the health care provider as soon as possible

D) Check for any increase in the amount of thoracic drainage

The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the heart. Which of these demonstrates the normal pathway?

A) AV node, SA node, Bundle of His, Purkinje fibers

B) Purkinje fibers, SA node, AV node, Bundle of His

C) Bundle of His, Purkinje fibers, SA node , AV node

D) SA node, AV node, Bundle of His, Purkinje fibers

When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first?

A) Try to vigorously stimulate normal breathing

B) Ask the RN to assess the vital signs

C) Measure the pulse oximetry

D) Continue to monitor respirations

When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because

A) Normal patterns of behavior may be labeled as deviant, immoral, or insane

B) The meaning of the client's behavior can be derived from conventional wisdom

C) Personal values will guide the interaction between persons from 2 cultures

D) The nurse should rely on her knowledge of different developmental mental stages

The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?

A) Assign an RN to provide total care of the client

B) Assign a nursing assistant to help the client with self-care activities

C) Delegate complete care to an unlicensed assistive personnel

D) Supervise a nursing assistant for skin care

The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process?

A) Assist a client post cerebral vascular accident to ambulate

B) Feed a 2 year-old in balanced skeletal traction

C) Care for a client with discharge orders

D) Collect a sputum specimen for acid fast bacillus

After working with a very demanding client, an unlicensed assistive personnel(UAP) tells the nurse, "I have had it with that client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond by saying

A) He has a lot of problems. You need to have patience with him.

B) "I will talk with him and try to figure out what to do."

C) "He is scared and taking it out on you. Let's talk to figure out what to do."

D) "Ignore him and get the rest of your work done. Someone else can take care of him forthe rest of the day."

A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements?

A) I am sorry. Referral information can only be provided by the client's health care providers.

B) "I can never give any information out by telephone. How do I know who you are?"

C) Since this is a referral, I can give you this information.

D) I need to get the client's written consent before I release any information to you.

A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that

A) A referral is needed to the psychiatrist who is to provide the client with answers

B) The client has a right to know about the prescribed medications

C) Such education is an independent decision of the individual nurse whether or not to teach clients about their medications

D) Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects

Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?

A) "Have the client sit on the side of the bed for at least 2 minutes before helping him stand."

B) "If the client is dizzy on standing, ask him to take some deep breaths."

C) "Assist the client to the bathroom at least twice on this shift."

D) "After you assist him to the chair, let me know how he feels."

The nurse receives a report on an older adult client with middle stage dementia.What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client

A) Has had a change in respiratory rate by an increase of 2 breaths

B) Has had a change in heart rate by an increase of 10 beats

C) Was minimally responsive to voice and touch

D) Has had a blood pressure change by a drop in 8 mmHg systolic

A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is

A) "I must document and report any information."

B) "I can't make such a promise."

C) "That depends on what you tell me."

D) "I must report everything to the treatment team."

Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)?

A) Be with a client who self-administers insulin

B) Cleanse and dress a small decubitus ulcer

C) Monitor a client's response to passive range of motion exercises

D) Apply and care for a client's rectal pouch

A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should first

A) Focus on reality orientation to place and person

B) Assist with the report of the client's complaint to the police

C) Obtain more details of the client's claim of abuse

D) Document the statement on the client's chart with a report to the manager

A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with

A) A Dopamine drip IV with vital signs monitored every 5 minutes

B) A myocardial infarction that is free from pain and dysrhythmias

C) A tracheotomy of 24 hours in some respiratory distress

D) A pacemaker inserted this morning with intermittent capture

An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?

A) "How long have you been a UAP and what units you have worked on?"

B) "What type of care do you give on the surgical unit and what ages of clients?"

C) "What is your comfort level in caring for children and at what ages?"

D) "Have you reviewed the list of expected skills you might need on this unit?"

A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse's response should be to

A) Ask to not be assigned to this client or to work on another unit

B) Tell the client that such behavior is inappropriate

C) Inform the client that hospital policy prohibits staff to date clients

D) Discuss the boundaries of the therapeutic relationship with the client

In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize

A) Learning relaxation techniques

B) Limiting alcohol use

C) Eating smaller meals

D) Avoiding passive smoke

The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance?

A) Arterial septal defect

B) Patent ductus arteriosus

C) Aortic stenosis

D) Ventricular septal defect

Clients with mitral stenosis would likely manifest findings associated with congestion in the

A) Pulmonary circulation

B) Descending aorta

C) Superior vena cava

D) Bundle of His

The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women?

A) Low tar cigarettes are less harmful during pregnancy

B) There is a relationship between smoking and low birth weight

C) The placenta serves as a barrier to nicotine

D) Moderate smoking is effective in weight control

What is the best way for the nurse to accomplish a health history on a 14 year-old client?

A) Have the mother present to verify information

B) Allow an opportunity for the teen to express feelings

C) Use the same type of language as the adolescent

D) Focus the discussion of risk factors in the peer group

What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?

A) The disease will incubate longer and progress more slowly in this infant

B) The infant is very susceptible to infections

C) Growth and development patterns will proceed at a normal rate

D) Careful monitoring of renal function is indicated

While planning care for a preschool aged child, the nurse understands needs. Which of the following would be of the most concern to the nurse?

A) Playing imaginatively

B) Expressing shame

C) Identifying with family

D) Exploring the playroom

A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important to emphasize to the client?

A) Maintain a low sodium diet

B) Take a diuretic with lithium

C) Come in for evaluation of serum lithium levels every 1-3 months

D) Have blood lithium levels drawn during the summer months

While teaching a client about their medications, the client asks how long it will take before the effects of lithium take place. What is the best response of the nurse?

A) Immediately

B) Several days

C) 2 weeks

D) 1 month

The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include

A) Pointing out inconsistencies in speech patterns to correct thought disorders

B) Accepting client and the client's behavior unconditionally

C) Encouraging dependency in order to develop ego controls

D) Consistent limit-setting enforced 24 hours per day

Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called

A) Craving

B) Crashing

C) Outward bound

D) Nodding out

The nurse asks a client with a history of alcoholism about the client's drinking behavior. The client states "I didn't hurt anyone. I just like to have a good time, and drinking helps me to relax." The client is using which defense mechanism?

A) Denial

B) Projection

C) Intellectualization

D) Rationalization

One reason that domestic violence remains extensively undetected is

A) Few battered victims seek medical care

B) There is typically a series of minor, vague complaints

C) Expenses due to police and court costs are prohibitive

D) Very little knowledge is currently known about batterers and battering relationships

A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find?

A) S3 heart sound

B) Thready pulse

C) Flattened neck veins

D) Hypoventilation

An explosion has occurred at a high school for children with special needs and severe developmental delays. One of the students accompanied with a parent is seen at a community health center a day later. After the initial assessment the nurse concludes that the student appears to be in a crisis state. Which of these interventions based on crisis intervention principles is appropriate to do next?

A) Help the student to identify a specific problem

B) Ask the parent to identify the major problem

C) Ask the student to think of different alternatives

D) Examine with the parent a variety of options

Which statement made by a client to the admitting nurse suggests that the client is experiencing a manic episode?

A) "I think all children should have their heads shaved.

B) "I have been restricted in thought and harmed."

C) I have powers to get you whatever you wish, no matter the cost.

D) "I think all of my contacts last week have attempted to poison me."

A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland." The nurse would document this behavior as

A) Perseveration

B) Circumstantiality

C) Neologisms

D) Flight of ideas

During the change-of-shift report the assigned nurse notes a Catholic client is scheduled to be admitted for the delivery of a ninth child. Which comment stated angrily to a colleague by this nurse indicates an attitude of prejudice?

A) I wonder who is paying for this trip to the hospital?

B) I think she needs to go to the city hospital.

C) All those people indulge in large families!

D) Doesn't she know there's such a thing as birth control?

Which of these statements by the nurse reflects the best use of therapeutic interaction techniques?

A) You look upset. Would you like to talk about it?

B) "I'd like to know more about your family. Tell me about them."

C) "I understand that you lost your partner. I don't think I could go on if that happened to me."

D) "You look very sad. How long have you been this way?"

A nurse in the emergency department suspects domestic violence as the cause of a client's injuries. What action should the nurse take first?

A) Ask client if there are any old injuries also present

B) Interview the client without the persons who came with the client

C) Gain client's trust by not being hurried during the intake process

D) Photograph the specific injuries in question