Exit Hesi

Question 1

Exit Hesi. A client is admitted to the emergency department (ED) with a blunt head injury and upper body trauma following a motorcycle collision. Which assessment finding warrants immediate intervention by the nurse?

• A. Rib pain with deep inspiration.
• B. Nausea with projectile vomiting.
• C. Rebound abdominal tenderness.
• D. Diminished bilateral breath sounds.

Question 2 (Case Study 1 of 6)

Which findings need further evaluation by the nurse? (Select all that apply.)

• Disoriented to time and place, disoriented to time and situation.
• Slurred speech and balance disturbances.
• Jaundice of sclera.
• Tachycardia.
• Blood pressure: 146/91 mmHg.
• Distended abdomen.
• Jaundice.
• Spider angiomas to the chest and abdomen.
• Generalized bruising in various stages of healing.

Question 3 (Case Study 2 of 6)

Based on the client’s assessment data, indicate whether the symptom is a finding of Thrombocytopenia, Cerebral Vascular Accident (CVA), or Liver Disorder.

• Generalized bruising: Thrombocytopenia & Liver Disorder.
• Disorientation: CVA & Liver Disorder.
• Slurred speech: CVA & Liver Disorder.
• Jaundice: Liver Disorder.
• Hepatomegaly: Liver Disorder.

Question 4 (Case Study 3 of 6)

The client is at the highest risk for [Hepatitis] as a result of [Substance use]. Exit Hesi

Question 5 (Case Study 4 of 6)

Indicate whether the following nursing actions are Indicated or Contraindicated for the client’s plan of care.

• Encourage a high calorie regular diet: Contraindicated.
• Assist with ambulation with 1 person assist: Contraindicated.
• Assess level of consciousness: Indicated.
• Monitor for bleeding: Indicated.
• Prepare to insert an esophageal balloon tamponade tube: Contraindicated.

Question 6 (Case Study 5 of 6)

Match the client goals to the appropriate dimension of care.

• Prevent hemorrhage and death: Promote safety.
• Identify complications such as hypokalemia, dehydration, and hypernatremia: Monitor fluid and electrolyte balance.
• Evaluate the effects of cirrhosis related inflammation: Infection prevention.
• Decrease abdominal pressure and the risk for a variceal bleed: Nursing safety priority.

Question 7 (Case Study 6 of 6)

The nurse evaluates the client’s response to care on day 2. Which findings indicate the client is responding to care? (Select all that apply.)

• A. Alert and oriented to person, place, time, and situation.
• B. Blood pressure 136/81 mmHg.
• C. 180 mL clear amber urine in 4 hours.
• F. Mild dyspnea with exertion.
• G. Medium bowel movement that is soft, brown.

Question 8

The nurse is checking the restraint on a client’s wrist and finds that the tie was attached to a movable portion of the bed frame and secured with a knot that was not easily released. Which action should the nurse take?

• A. Move the ties so the restraints are secured to the side rails.
• B. Ensure that the knot can be quickly released.
• C. Ensure that the restraints are snug against the client’s wrists.
• D. Tie the knot with

Question 9

The nurse-manager of a surgical clinic observes a practical nurse (PN) positioning a client for a sigmoidoscopy. The PN has the client in a flat prone position. Which action should the nurse implement?

• A. Ask a secondary unlicensed assistive personnel (UAP) to assist the PN with the procedure.
• B. Direct the PN to obtain a procedure tray before the healthcare provider arrives.
• C. Demonstrate to the PN how to position the client more effectively for the procedure.
• D. Assume responsibility for the client’s care so the PN can observe the procedure. Exit Hesi

Question 10

A client with an endotracheal tube (ETT) is being mechanically ventilated. Which method(s) should the nurse use to determine if the ETT is correctly placed? (Select all that apply.)

• A. Auscultate for presence of bilateral breath sounds.
• B. Assess for symmetrical chest movement.
• C. Monitor ETT markings between 22 and 26 cm at teeth line.
• D. Check for capillary refill of 3 seconds or less.
• E. Obtain a portable chest x-ray to verify ETT location.

Question 11

A client with a flare of rheumatoid arthritis (RA) is being discharged. Which instruction is most important for the nurse to include in the discharge teaching?

• A. Take prescribed cortisone accurately.
• B. Use a walker when weakness occurs.
• C. Avoid extreme environmental temperatures.
• D. Decrease daily intake of sodium in diet.

Question 12

The nurse is caring for two clients in the critical care unit (CCU). One client is being mechanically ventilated, and the other client is two days post-thoracotomy and is reporting incisional pain. Which action should the nurse perform first?

• A. Complete a head-to-toe assessment on the client who is being mechanically ventilated.
• B. Change the surgical dressing for the client who had the thoracotomy.
• C. Assess the level of consciousness and vital signs for both clients.
• D. Review the plan of care and scheduled medications for both clients.

Question 13

A client with Borderline Personality Disorder (BPD) tells the day shift nurse, “You are my favorite nurse. The night nurse is so aloof and doesn’t care about me at all.” Which response is best for the nurse to provide to this client’s dichotomous tendency?

• A. “I am happy that you are getting better and will be able to go home.”
• B. “Tomorrow I will talk to that nurse about how you were treated last night.”
• C. “I am glad you like me. Which nurse was acting aloof to you?”
• D. “What did the night nurse do that makes you think the nurse is aloof?”

Question 14

A female client is brought to the emergency department (ED) after being sexually assaulted. The client is crying and states, “I don’t exactly remember what happened. I think I was raped, but I’m not sure.” How should the nurse respond?

• A. “Yes, I can see. Tell me more about what you remember.”
• B. “It is OK to cry, but first we need to take care of your injuries.”
• C. “He hurt you? What makes you think you were raped?”
• D. “Did you try to resist or fight back when you were attacked?”

Question 15

A client who is at 38-weeks gestation is admitted to the labor and delivery unit with profuse vaginal bleeding. Which assessment finding should the nurse report to the healthcare provider?

• A. Sharp fundal pain and uterine tenderness.

• B. Increase in pulse and fetal rate reactivity.
• C. Mild discomfort and elevated blood pressure.
• D. Pain in lower quadrant and oliguria.

Question 16

A young adult client with depression is seen in the clinic. The client describes feeling less depressed after taking the medication for the past couple of weeks but now wants to discontinue the medication because of the side effects. Which response is best for the nurse to provide?

• A. Remind the client that feeling better is the therapeutic effect of the medication.
• B. Tell the client to discuss the medication side effects with the healthcare provider (HCP).
• C. Tell the client that the medication’s side effects will most likely dissipate over time.
• D. Inform the client that gradual tapering must be used to discontinue the medication.

Question 17

The nurse is providing discharge teaching for a client with Addison’s disease. Which information is most important for the nurse to include in the client’s instructions for self-management?

• A. Importance of recording daily weights.
• B. Adherence to a high fiber, low fat diet.
• C. Need to check temperature daily.
• D. Events requiring steroid dose adjustments.

Question 18

The parents of a 3-year-old child who is toilet trained tell the nurse that the child has been soiling the bed since being admitted to the hospital. Which information should the nurse provide to the parents?

• A. Diapering will be provided since hospitalization is stressful to preschoolers.
• B. A retraining program will need to be initiated when the child is discharged.
• C. Children usually resume their toileting behaviors when they leave the hospital.
• D. A potty chair should be brought from home to provide the child with a familiar routine.

Question 19

A client who is at 26-weeks gestation is positioned in the lithotomy position for a scheduled procedure. The client suddenly reports feeling dizzy and the nurse observes that the client is pale and diaphoretic. Which action should the nurse implement?

• A. Instruct the client to take deep breaths.
• B. Place a wedge under the client’s hip.
• C. Place the client in the Trendelenburg position.
• D. Remove the client’s legs from the stirrups.