HESI Exit Actual Final Exam
1. The nurse cares for a client with a cuffed tracheostomy
tube. Before performing oral care, the nurse notes that the
client's tracheostomy cuff is inflated. Which of the following
is the MOST appropriate action for the nurse to take?: Leave
the cuff inflated and suction through the tracheostomy.
2. A young adult brings a friend to the emergency
department and states that the friend has been using heroin.
Which action by the nurse is the MOST appropriate?: Assess
oxygen saturation levels.
3. The client tells the clinic nurse that the client is thinking
about using nicotine polacrilex (Nicorette). Which question is
MOST important for the nurse to ask?: "Have you ever had
chest pain?"
4. The nurse cares for the client with a client controlled
analgesia (PCA) pump. The nurse determines that the client
has pressed the button 11 times and received 6 doses of
morphine during the last hour. Which is the MOST
appropriate action for the nurse to take?: Ask the client to
describe the pain.
Assessment: outcome priority; must validate that client is in pain
before implementation
5. A pregnant woman receives an epidural anesthetic.
After administration of the epidural anesthetic, the client's
blood pressure changes from 120/84 to 94/50. Which action
by the nurse is MOST appropriate?: Place the client on her left
side with her legs flexed.
Implementation: outcome desired; will increase venous return and
cardiac output; fetal pressure on inferior vena cava reduced
6. A nursing order, "Increase fluid intake" is written for a
client diagnosed with dehydration. Which finding BEST
indicates improving fluid status?: Urinary output of 1,500 mL in
24 hours.
Assessment: outcome priority; increased amounts of antidiuretic
hormone secreted; urine output decreased and concentrated
7. The nurse prepares to administer the initial dose of oral
enalapril (Vasotec) 20 mg in the morning. Which medication
should the nurse question giving to the client?: 40 mg oral
furosemide (Lasix) in the morning.
Implementation: outcome potential problem; may promote
significant diuresis; first dose of ACE inhibitors increases risk of
"first dose" phenomenon due to vasodilation; combination of
vasodilation and diuresis increases risk of orthostatic hypotension
8. The home care nurse visits a client with a halo fixator
traction device. Which client statement MOST concerns the
nurse?: "I drove to the library yesterday." Implementation:
outcome not desired and may be a problem; client is not able to
turn with halo device; increases the risk of injury to self and others
9. The nurse cares for a client diagnosed with depression.
Which statement by the client indicates improvement?: The
nurse cares for a client diagnosed with depression. Which
statement by the client indicates improvement?
The nurse cares for a client diagnosed with depression. Which
statement by the client indicates improvement?
10. The nurse on the maternity unit must accept a transfer
client from a medical/surgical unit. The nurse considers
which transfer client appropriate?: A 38-year-old client with a
diagnosis of systemic lupus erythematosus.
Implementation: outcome desired; autoimmune disease; not
infectious
11. The nurse in the outclient surgery unit prepares a 4-
year-old child for surgery. It is MOST important for the nurse
to make which of these statements?: "Take this doll and show
me where the operation will be done."
Implementation: outcome desired; encourage expression of
feelings (e.g., anger); fear mutilation; allow child to play with
models of equipment
12. The nurse cares for a client diagnosed with Alzheimer's
disease. The client is confused and incontinent of urine.
What is the MOST important action for the nurse to take?:
Assist the client to a bedside commode every 2 hours.
Implementation: outcome desired; keeps client active and
independent
13. The nurse cares for a client with a history of type 1
diabetes mellitus who has just returned to the surgical acute-
care unit after a right below-knee amputation. The client's
capillary blood glucose is 480 mg/dL. The postoperative
orders indicate 6 units of regular insulin subcutaneously
should be administered. Which of the following is the FIRST
action the nurse should take?: Administer the 6 units of regular
insulin
Implementation: outcome desired; sliding scale-receives
predetermined amount of insulin according to glucose level;
surgery and infection increase insulin needs 14. During the
admission interview, the client reports a red, itchy raised
rash on the chest and lip swelling after use of aspirin and
penicillin. The admission orders include bed rest, soft diet as
tolerated, naproxen (Naprosyn), and cefaclor (Ceclor). Which
is the BEST description of expected breath sounds heard
during auscultation?: Do not administer the Ceclor or naproxen;
notify the healthcare provider.
Implementation: outcome desired; both medications should be
withheld; risk of hypersensitivity reaction
15. The nurse teaches a client about how to care for an
ileostomy. Which comment, if made by the client to the
nurse, indicates further teaching is needed?: "I should take
polyethylene glycol (MiraLax) with a large glass of water."
Implementation: outcome not desired; osmotic laxative and is
contraindicated; avoid enteric-coated or capsule medication, which
may not be absorbed through GI tract 16. The nurse cares for a
client diagnosed with chronic bronchitis and peripheral
vascular disease. The nurse expects to assess which of these
breath sounds?: Deep, low-pitched rumbling sounds are heard
mainly on expiration.
Assessment: outcome expected; sonorous wheezes or rhonchi,
caused by mucus in the airways; excessive mucous production is
primary symptom
17. The nurse prepares to administer gentamicin
(Garamycin) to the 65-year-old client. Which is the MOST
important action for the nurse to take prior to administration
of the medication?: Monitor the serum BUN and creatinine.
Assessment: outcome priority; nephrotoxic; will see proteinuria,
oliguria, hematuria, thirst, increased BUN, decreased creatine
clearance
18. The nurse cares for the client in the labor unit. During
the transitional phase of labor, the umbilical cord becomes
prolapsed. It is MOST important for the nurse to take which
action?: Place the client supine with the foot of the bed elevated.
Implementation: outcome desired; Trendelenburg or knee chest
position desired to decrease pressure on umbilical cord
19. The nurse cares for the client diagnosed with lung
cancer. The family states that the client has become
confused and that urinary output has decreased during the
previous 24 hours. Which finding MOST concerns the
nurse?: Sodium 128 mEq/L.
Assessment: outcome desired and priority; normal sodium range is
135-145 mEq/L, dilutional hyponatremia due to SIADH; client is
neurologically depressed with increased risk of seizures
20. The home care nurse cares for a client who is diagnosed
with hypertension and mild depression. The client's daughter
states that her mother has been falling frequently. WWhich
response by the nurse is BEST?: "When does your mother
fall?"
Assessment: outcome priority; nurse needs to determine what the
problem is before implementing; recent history of falling is most
important contributor to increased risk of falls
21. A femoral angiogram is scheduled for a client. It is
MOST important for the nurse to take which action prior to
the angiogram?: Locate and note the presence of peripheral
pulses.
Assessment: outcome desired and priority; pulse location may be
marked according to facility policy; important to get baseline
assessment of color, motion, temperature and sensitivity of
extremities as well as strength and equality of pulses
22. A child sustains a crushing chest injury in a car
accident. In the emergency room, an endotracheal tube is
inserted. Several hours later the nurse enters the client's
room and finds the child in respiratory distress. It is MOST
important for the nurse to take which action prior to the
angiogram?: Listen to the client's breath sounds.
Assessment: outcome priority; will give early and clearest
indication of respiratory status, will hear changes with narrowed
airways, fluid in alveoli or pneumothorax 23. The nurse cares for
an elderly man diagnosed with Alzheimer's disease. It is
MOST important for the nurse to take which action?: .
Frequently inform the client of the room and bathroom location.
Implementation: outcome desired; provides for safety needs and
frequent orientation 24. The nurse is responsible for triage of
injured residents of an apartment building that collapsed
during a tornado. Which client should the emergency
personnel see FIRST?: A 48-year-old client with severe head
trauma. Blood pressure 168/52, pulse 58 per minute, irregular
respirations at 12/minute.
Real problem; vitals signs indicate significant increase in
intracranial pressure; most unstable client
25. The nurse cares for a client diagnosed with Crohn's
disease. The nurse instructs the client about diet. Which
menu selection indicates to the nurse that teaching is
effective?: Baked cod, biscuit without butter, fruit roll-up.
Implementation: outcome desired; low-fat, high-protein, low-
residue, nonirritating, high in calories, minerals
26. The nursing team consists of one RN, one LPN/LVN and
two nursing assistive personnel (NAPs). Which assignment
is MOST appropriate for the LPN/LVN?: A 78-year-old client
diagnosed with a thrombotic cerebrovascular accident 5 days
Outcome desired; LPN/LVN can care for stable clients with
expected outcomes; nothing in question indicates instability; as
cerebral edema resolves, the condition will improve
27. The nurse cares for a client during a 24-hour urine
specimen collection. Several hours later, the client tells the
nurse that she has started to menstruate. Which action by
the nurse is MOST appropriate?: Inform the health care
provider that the client is menstruating.2. Send the urine collected
prior to the onset of the client's menstruation to the lab.
Implementation: outcome desired; menstruation may last several
days to a week; protein and red cells may alter the results of the
urinalysis
28. The nurse cares for the client in the recovery room after
a knee surgery procedure. The client has an oral airway in
place. Which is the BEST indicator that the oral airway can
be removed?: The client tries to chew on the oral airway..
Assessment: outcome priority; client is alert and able to maintain
his own airway 29. The nurse cares for clients in the
antepartum clinic. Which client should the nurse see FIRST?
1. An 18-year-old multigravida client at 28 weeks gestation
with a positive indirect Coombs' test.
2. A 24-year-old multigravida client at 32 weeks gestation
with moderate facial edema.
3. A 30-year-old client at 26 weeks gestation with bilateral
yellow breast exudate.
4. A 43-year-old primigravida client at 18 weeks of
gestation reporting an absence of fetal movement.: A 24-
year-old multigravida client at 32 weeks gestation with moderate
facial edema.
A 24-year-old multigravida client at 32 weeks gestation with
moderate facial edema. 30. The nurse instructs a client about
include digoxin (Lanoxin), furosemide
(Lasix), spironolactone (Aldactone), and a low-sodium diet.
Which statement by the client indicates the need for further
instruction?
1. "I should weigh myself every morning and call the
health care provider if I gain more than a couple of pounds in
a few days."
2. "I should call the health care provider immediately if I
start to feel nauseated or have difficulty breathing with
normal activities."
3. "I plan to use salt substitutes now that I have to limit my
sodium intake."4. "I should read food and nonprescription
medication labels to check the ingredients.": "I plan to use salt
substitutes now that I have to limit my sodium intake."
Implementation: outcome not desired; salt substitutes contain
potassium; spironolactone is a potassium-sparing diuretic
31. The nurse cares for a client scheduled for a femoral
popliteal bypass procedure. When the nurse approaches the
client with the informed consent form, the client says, "I don't
need to talk to anybody about this procedure. I already know
everything I need to know about it." Which response by the
nurse is BEST?1. "After I explain the operation to you, both of
us will sign the form for legal purposes and it will be placed in
your chart."2. "Tell me what the healthcare provider told you
about the risks and benefits of this operation."3. "Can I answer
any questions that you have about the procedure?"4. "You
should read all these materials to be sure that you understand
everything about this procedure."
1) Implementation: outcome not desired; nurse should not
explain the procedure; the health care provider doing the
procedure should explain the risks and benefits2) CORRECT -
Assessment: outcome desired; nurse should determine if
client understands risks and benefits of the procedure before
the client and nurse sign the informed consent form3)
Implementation: outcome not desired; yes/no question non-
therapeutic response4) Implementation: outcome desired but
not priority; reading materials do not ensure that client
understands risks and benefits of the procedure
A man scheduled for a vasectomy tells the nurse that he and
his wife are involved in a monogamous relationship. Which
statement by the nurse is
BEST?
1. "You will need to wear a condom when having sexual