HESI Exit Exam 2 – Question and Answers


Category: HESI Exit Exam Tag: hesi exit


HESI Exit Exam with Answers

  1. A nurse on the psychiatric unit of the hospital has been assigned four clients for the shift. The assignment includes an 84-year-old client who is severely depressed, a 73-year-old client who is being discharged, a 53-year-old client who was admitted for lithium toxicity, and a 48-year-old client who has panic attacks. Which client should the nurse evaluate first after receiving report?
  2. A young female client admitted to the trauma center after being sexually assaulted continues to talk about the rape. Toward what goal should the primary nursing intervention be directed?
  3. A client is dying. Hesitatingly, his wife says to the nurse, “I’d like to tell him how much I love him, but I don’t want to upset him.” Which is the best response by the nurse?
  4. A nonviolent client on the psychiatric unit suddenly refuses to take the prescribed antipsychotic medication. What should the nurse do?
  5. Which psychotherapeutic theory uses hypnosis, dream interpretation, and free association as methods to release repressed feelings?
  6. A depressed client has been taking Paroxetine (Paxil) 20 mg by mouth once a day for 4 weeks. The practitioner concludes that there is no clinical improvement in the client’s condition and increases the daily dose to 30 mg. The medication is supplied in an oral suspension of 10 mg/5 mL. How many milliliters of Paxil solution should the nurse instruct the client to take? Record your answer using a whole number. __________ mL
  7. A parent of a 13-year-old adolescent with recently diagnosed Hodgkin disease tells a nurse, “I don’t want her to know about the diagnosis.” How should the nurse respond?
  8. A client who is to undergo dilation and curettage and conization of the cervix for cancer appears tense and anxious. What is the best approach for the nurse to support the client emotionally?
  9. A client in the hyperactive phase of a mood disorder, bipolar type, is receiving lithium. A nurse sees that the client’s lithium blood level is 1.8 mEq/L. What is the most appropriate nursing action?
  10. An 18-year-old woman is brought to the emergency department by her two roommates after being found unconscious in the bathroom. Laboratory tests are ordered. The nurse reviewing the findings notes that the urinalysis is positive for flunitrazepam (Rohypnol). The nurse knows that flunitrazepam is often used:
  11. In the second stage of labor, the nurse should plan to discourage a client from holding her breath longer than 6 seconds while pushing with each contraction. What complication does this prevent?
  12. A nurse is aware that after the administration of alprazolam (Xanax) is started, it is important to observe the client for side effects. What is the nurse’s initial action?
  13. A 6-year-old child is found to have type 1 diabetes. In light of the child’s cognitive developmental level, which explanation of the illness is most appropriate?
  14. A client is scheduled for amniocentesis. What should the nurse do before the procedure?
  15. A woman has just received the news that she is pregnant. She is ambivalent about the pregnancy because she had planned to go back to work when her youngest child started school next year. What developmental task of pregnancy must the woman accomplish in the first trimester of pregnancy?
  16. A married male client with three children has lost his job and states that he feels useless. He is tearful, upset, and embarrassed. What is an appropriate objective of care for this client?
  17. A health care provider prescribes oxazepam (Serax) for a client who is beginning to experience withdrawal symptoms while undergoing detoxification. What are the primary reasons that oxazepam is given during detoxification?
  18. A nurse is aware that a co-worker’s mother died 16 months ago. The co-worker cries every time someone says the word “mother” and when the mother’s name is mentioned. What does the nurse conclude about this behavior?
  19. What prenatal teaching is applicable for a client who is between 13 and 24 weeks’ gestation?
  20. When a client at 39 weeks’ gestation arrives at the birthing suite she says, “I’ve been having contractions for 3 hours, and I think my water broke.” What will the nurse do to confirm that the membranes have ruptured?
  21. When working with clients who use manipulative socially acting-out behaviors, the nurse should be:
  22. A male nurse is caring for a client. The client states, “You know, I’ve never had a male nurse before.” What is the best reply by the nurse?
  23. A 14-year-old emancipated minor at 22 weeks’ gestation comes in for her second prenatal examination. As she enters the examination room with her mother, she tells the nurse that she does not want her mother present for the examination. What should the nurse say?
  24. Which statement by the client indicates to the nurse that the teaching about taking an antidepressant medication has been understood?
  25. A depressed client has been receiving venlafaxine (Effexor) 25 mg three times a day by mouth. The health care provider increases the dose to 37.5 mg three times a day by mouth. The pharmacy supplies scored 25-mg tablets of Effexor. How many tablets should the nurse administer? Record your answer using one decimal place. _________ tablets
  26. A nurse leads an assertiveness training program for a group of clients. Which statement by a client indicates that the treatment has been effective?
  27. What should a nurse consider about the past life of clients who have immigrated to this country?
  28. Which relationship is of most concern to the nurse because of its importance in the formation of the personality?
  29. A client at 35 weeks’ gestation is experiencing contractions. Her cervix is dilated 2 cm. The nurse teaches the client that sexual activity, particularly intercourse, should be:
  30. A 28-year-old woman comes into the clinic and tells the nurse that she fears that she is infertile because she has been trying to become pregnant for 2 years. While collecting the health history the nurse learns that the client experiences irregular and infrequent menstrual periods. The client is overweight and has severe acne and alopecia. The health care provider diagnoses polycystic ovarian syndrome (PCOS). Which of the following interventions is the most important?
  31. A client in active labor starts screaming, “The baby is coming! Do something!” What is the first nursing action?
  32. The nurse is conducting teaching for a client being discharged after an abdominal hysterectomy. Which statement by the client indicates a need for further teaching?
  33. A nurse is assigned an adolescent who gave birth 12 hours ago. She continually talks on the phone to her friends and does not respond when her new baby cries. What is the best immediate intervention?
  34. A terminally ill client tells the nurse, “I would love to learn to speak German before I die.” The nurse’s response to the client’s desire to learn a foreign language should be based on an understanding that:
  35. What drug should a nurse anticipate that the health care provider will prescribe for a client demonstrating clinical manifestations associated with an opioid overdose?
  36. A 1-day-old newborn has just expelled a thick, greenish-black stool. The nurse determines that this is the first stool. What should the nurse do next?
  37. A newborn has small, whitish, pinpoint spots over the nose that are caused by retained sebaceous secretions. When documenting this observation, a nurse identifies them as:
  38. The nurse assures a breastfeeding mother that one way she will know that her infant is getting an adequate supply of breast milk is if the infant gains weight. What behavior does the infant exhibit if an adequate amount of milk is being ingested?
  39. A nurse plans to administer vitamin K to a newborn. What site should the nurse use for the injection?
  40. A mother is inspecting her newborn girl for the first time. The infant’s breasts are edematous, and she has a pink vaginal discharge. How should the nurse respond when the mother asks what is wrong?
  41. A newborn’s total body response to noise or movement is often distressing to the parents. What should the nurse explain about this response?
  42. How should a nurse screen the newborn of a diabetic mother for hypoglycemia?
  43. A health care provider determines that a fetus is in a breech presentation. For which complication should the nurse monitor the client?
  44. A new mother exclaims to the nurse, “My baby looks like a Conehead!” How should the nurse respond?
  45. On the second day of life, minutes after drinking 2½ ounces of formula, a newborn regurgitates about half an ounce. The mother remarks, “My baby spits up after every feeding.” What should the nurse do next?
  46. What should the nurse do to enhance a neonate’s behavioral development?
  47. A nurse is assessing a newborn for signs of hyperbilirubinemia (pathological jaundice). What clinical finding confirms this complication?
  48. A nurse who is caring for a 32-week appropriate-for-gestational-age (AGA) neonate establishes a list of objectives for the infant. What objective should receive the highest priority?
  49. During a follow-up appointment, a client at 21 weeks’ gestation is found to have hyperemesis gravidarum. The client says, “Why is this happening to me? I don’t know whether I can continue like this.” What is the best response by the nurse?
  50. A new mother who has begun breastfeeding asks for assistance removing the baby from her breast. What should the nurse teach her?
  51. A nonstress test (NST) is scheduled for a client with mild preeclampsia. During the test, the client asks the nurse what it means when the fetal heart rate goes up every time the fetus moves. What should the nurse consider before responding?
  52. A nurse is caring for four clients, each with a different medical condition. Which condition should the nurse anticipate will result in the client’s being instructed by the health care provider not to breastfeed?
  53. A client who underwent a mastectomy because of breast cancer is now undergoing chemotherapy, which has caused hair loss. The client states, “I feel like I’ve lost my sense of power.” What is the nurse’s best response?
  54. What is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks’ gestation?
  55. The nurse administers the prescribed vitamin K intramuscularly to a newborn immediately after birth to:
  56. A client being prepared for surgery because of a ruptured tubal pregnancy complains of feeling lightheaded. Her pulse is rapid, and her color is pale. What condition does the nurse anticipate as a common complication of a ruptured tubal pregnancy?
  57. A nurse is caring for several pregnant clients in the prenatal clinic. Which client causes the most concern because of her predisposition to placenta previa?
  58. A nurse in the clinic determines that a 4-day-old neonate who was born at home has a purulent discharge from the eyes. What condition does the nurse suspect?
  59. A new mother asks a nurse how to care for her baby’s umbilical cord stump. What should the nurse teach the mother?
  60. A nurse is reviewing the laboratory report of a newborn whose hematocrit level is 45%. What value denotes a healthy infant?
  61. While mopping the kitchen floor, a client at 37 weeks’ gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations?
  62. A client in the 38th week of gestation exhibits a slight increase in blood pressure. The health care provider advises her to remain in bed at home in a side-lying position. The client asks why this is important. What is the nurse’s response regarding the advantage of this position?
  63. While being admitted for a lumpectomy the client begins to cry and says, “I found the lump a few months ago, but I didn’t go to the doctor because of what it could be.” How should the nurse reply?
  64. A client has a cesarean birth. What is the most important nursing intervention to prevent thromboembolism on the client’s first postpartum day?
  65. A nurse who is caring for a client in labor uses nitrazine paper to test the pH of the client’s leaking vaginal fluid. What color will the nitrazine paper turn if the leakage is amniotic fluid?
  66. An infant is born with a bilateral cleft palate. Plans are made to begin reconstruction immediately. What nursing intervention should be included to promote parent-infant attachment?
  67. A nurse is giving discharge instructions to a new mother. What is the most important instruction to help prevent postpartum infection?
  68. An infant has surgery for repair of myelomeningocele. For which early sign of impending hydrocephalus should the nurse monitor the infant?
  69. A new mother asks the nurse whether she may wash her baby in a tub after they go home. What is the nurse’s best response?
  70. After the birth of a neonate, a parent asks, “What is that white substance over the baby’s body?” The nurse initially responds:
  71. Phototherapy is prescribed for a neonate with hyperbilirubinemia. Which nursing intervention is appropriate to reduce the potentially harmful side effect of phototherapy?
  72. A client’s membranes rupture during the transition phase of labor, and the amniotic fluid appears pale green. What priority intervention for the infant can the nurse anticipate implementing upon delivery?
  73. A 6-month-old infant weighing 15 lb is admitted with a diagnosis of dehydration. A prescription for oral rehydration therapy 4 mL/kg Pedialyte over 4 hours is made. What is the approximate amount of fluid that the infant should ingest during the 4 hours?
  74. A nurse determines that a 1-day-old newborn has a heart rate of 138 beats/min. What is the best nursing action at this time?
  75. Abdominal surgery is planned for a 2-month-old infant. Which item should the nurse provide for the infant on the day of surgery?
  76. The parents of a 6-week-old infant who was born without an immune system ask the nurse why their baby is still so healthy. What is the best response by the nurse?
  77. A mother who is visiting the pediatric clinic with her 10-month-old son tells the nurse how pleased she is with her chubby infant. She exclaims, “Look how much weight he’s gained even though he drinks only orange juice! He won’t drink any milk!” What is the best response by the nurse.
  78. On the third postpartum day a mother visits the clinic and asks why her newborn’s skin has begun to appear yellow. The nurse explains that the change in her infant’s skin tone is the result of:
  79. An infant is receiving intermittent nasogastric tube feedings. In what position should the nurse place the infant?
  80. A nurse is discussing the diet of an 8-month-old infant with the parents. Which foods can an infant of this age on a regular diet safely be fed? (Select all that apply.)
  81. The parents of an infant with newly diagnosed cystic fibrosis ask a nurse what causes the foul-smelling, frothy stool. What is the best response by the nurse?
  82. A client in labor is admitted to the birthing unit. Assessment reveals that the fetus is in a footling breech presentation. What should the nurse consider about breech presentations when caring for this client?
  83. An 8-month-old infant undergoes surgical correction for hypospadias. What is a priority nursing intervention during the postoperative period?
  84. The mother of a 5-month-old boy calls the nurse in the pediatric clinic to ask why her son no longer turns his head toward her breast when she touches his cheek. How should the nurse respond?
  85. A gavage feeding is prescribed for an infant. How does the nurse determine the length of the tube needed to reach the stomach?
  86. A 6-month-old infant is brought to the emergency department in severe respiratory distress. A diagnosis of respiratory syncytial virus (RSV) infection is made and the infant is admitted to the pediatric unit. What should be included in the nursing plan of care?
  87. An infant is born with a cleft lip. What nursing intervention is unique to infants with cleft lip?
  88. A nurse in the pediatric clinic is caring for an 11-month-old infant with iron-deficiency anemia. The infant’s hemoglobin is 8 g/dL. What does the nurse expect to observe when evaluating the infant?
  89. A client gives birth to a full-term male with an 8/9 Apgar score. What should the immediate nursing care of this newborn include?
  90. A 9-month-old infant who appears well-nourished, alert, and happy is brought to the well-baby clinic for a routine physical examination. Using Erikson’s theory of development, the nurse determines that the infant is in the process of achieving the task of:
  91. The parents of a 5-month-old infant tell a nurse at the well-baby clinic that they are concerned because their baby weighs only 14 lb. After reviewing the infant’s health history, the nurse assures them that their baby’s weight is within the expected range for age. What information prompted this reply?
  92. An infant has been admitted with failure to thrive (FTT). The nurse knows that more education is required when she hears one of the parents say:
  93. A nurse is planning to obtain a blood specimen from a 4-week-old high-risk infant in the neonatal intensive care unit to test for hypoglycemia. At which point, on the figure of the bottom of the infant’s foot, should the automatic lancet device be placed?
  94. A parent brings a 2-month-old infant with Down syndrome to the pediatric clinic for a physical and administration of immunizations. Which clinical finding should prompt the nurse to have further assessment by the care provider?
  95. A parent of a 6-month-old infant asks the nurse which foods should be introduced first. What is the best response by the nurse?
  96. A nurse is observing two 18-month-old children playing side by side in a sandbox. Although they watch each other, neither interacts with the other. What type of play does the nurse identify?
  97. A 13-month-old child is undergoing a lumbar puncture for confirmation of a diagnosis of bacterial meningitis. During the procedure the nurse notes that the spinal fluid is cloudy. What does this finding indicate?
  98. A nurse in the pediatric clinic receives a call from a mother who states that her 2½-year-old daughter, whom she discovered in a kitchen cabinet, is crying that her mouth hurts. She is drooling, and her tongue and gums are white. The nurse gives the mother the number of the poison control center, telling her to call immediately because the nurse suspects that the child has ingested:
  99. The mother of a 2-year-old child expresses concern to the nurse in the pediatric clinic that her child still takes a bottle of milk to bed at night. How should the nurse explain to the mother that this practice should be stopped?
  100. An unconscious toddler requires intermittent nasogastric feedings. When should the nurse check placement of the tube?
  101. A nurse is caring for a toddler who has undergone bone marrow transplantation. What clinical findings should the nurse anticipate if an infection develops?
  102. An IV of 800 mL/24 hr is prescribed for a 2½-year-old child. At how many milliliters per hour should the nurse set the volume control device?
  103. A client who is 21 weeks pregnant loses the baby because of an incompetent cervix. Once the client’s physical needs have been assessed and met, what is the best way for the nurse to meet the client’s psychological needs?
  104. A nurse is obtaining a health history from the mother of a 15-month-old toddler with celiac disease. The nurse expects the mother to indicate that her toddler:
  105. During a well-child visit the parents tell a nurse, “Our 3-year-old doesn’t listen to us when we speak—he ignores us!” An auditory screening reveals that the child has a mild hearing loss. What should the nurse explain to the parents about this degree of hearing loss?