Question 33 of 130
HESI Exit Q&A. The nurse reviews the client’s initial vital signs and presentation.
Drag from Word Choices to complete the sentence.
The nurse recognizes that __________, __________, and __________ should be assessed due to the client’s presentation.
Word Choices
- presence of night sweats
- chest pain
- swallowing ability
- sputum consistency
- stool characteristics
Answer: The nurse recognizes that presence of night sweats, chest pain, and sputum consistency should be assessed due to the client’s presentation.
Question 34 of 130
Which finding(s) are warning signs associated with lung cancer? Select all that apply.
- A Dyspnea
- B Runny nose
- C Tachycardia
- D Chest pain
- E Sputum
- F Hoarseness
- G Chills
- H Weight loss
- I Clubbing
Answer: The findings that are warning signs associated with lung cancer in this client include:
- I Clubbing (noted on fingernails)
- A Dyspnea (noted as “struggling to breathe”)
- D Chest pain (reported as “pressure pain in chest”)
- E Sputum (reported as “productive with blood streaked” and “rust colored”)
- F Hoarseness (noted as a change in voice sounds)
- H Weight loss (reported as “recent, large weight loss”)
Question 37 of 130
The nurse reviews the physician’s orders. For which potential complication(s) of a bronchoscopy should the nurse monitor? Select all that apply.
- A Pleural effusion
- B Pneumothorax
- C Dysrhythmia
- D Bronchospasm
- E Sepsis
- F Laryngospasm
- G Hemorrhage
Answer: The nurse should monitor for the following potential complications of a bronchoscopy:
- B Pneumothorax
- C Dysrhythmia
- D Bronchospasm
- F Laryngospasm
- G Hemorrhage
Question 36 of 130
The nurse gives 1 mg morphine to the client and plans to check pain relief in 15 to 30 minutes. The nurse recognizes the intravenous push route is helpful due to rapid titration. HESI Exit Q&A
For each item, click to indicate whether it is an appropriate or not an appropriate intervention for the nursing care plan. Each row must have only one response option selected.
| Intervention | Appropriate | Not appropriate |
| Mark drainage on chest tube | ○ | ○ |
| Administer 1 mg morphine every 4 hours around the clock | ○ | ○ |
| Ensure there is bubbling in the water seal chamber on the chest tube | ○ | ○ |
| Listen to lung sounds | ○ | ○ |
| Hang the chest tube on the side rail to keep even with the lungs | ○ | ○ |
| Remove dressing to inspect wound site | ○ | ○ |
| Tape all connections on chest tube | ○ |
Answer:
- Mark drainage on chest tube: Appropriate
- Administer 1 mg morphine every 4 hours around the clock: Appropriate
- Ensure there is bubbling in the water seal chamber on the chest tube: Not appropriate (Constant bubbling indicates an air leak)
- Listen to lung sounds: Appropriate
- Hang the chest tube on the side rail to keep even with the lungs: Not appropriate (Drainage system must be kept below the level of the chest)
- Remove dressing to inspect wound site: Not appropriate (Post-op dressings should generally remain intact unless saturated or per specific surgeon orders)
- Tape all connections on chest tube: Appropriate
Question 38 of 130
The nurse teaches the client about cancer treatment management interventions to follow, and monitor for, when getting chemotherapy.
Which client statements indicate the client understands the teaching regarding cancer treatment? Select all that apply.
- A Complete word puzzles for entertainment
- B Notify oncology healthcare provider if bleeding from gums
- C Plan to eat and drink when not nauseated
- D I will monitor my weight
- E Pacing myself during activities will be important
- F Eat hot chicken noodle soup
- G Drink less after chemotherapy to avoid nausea
- H Chicken with avocado is a good meal choice
Question 81 of 130
Which intervention is most important for the nurse to include in the plan of care for a client who is 12 hours post-thyroidectomy?
- A Maintain a semi-Fowler position.
- B Prepare to administer radioactive iodine treatments.
- C Anticipate and monitor for hypothermia.
- D Resume antithyroid drug therapy
Question 82 of 130
A client treated for type 2 diabetes mellitus for eight years arrives to the clinic describing elevated blood glucose readings intermittently for the past two months. Which information requires further assessment by the nurse?
Reference Range: Blood Urea Nitrogen (BUN) [10 to 20 mg/dL (3.6 to 7.1 mmol/L)] White Blood Cell (WBC) [5,000 to 10,000/mm³ (5 to 10 × 10⁹/L)] Blood Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)] Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]
- A Potassium 3.5 mEq/L (3.5 mmol/L).
- B White blood cell count 11,000/mm³ (11 × 10⁹/L).
- C Blood urea nitrogen 26 mg/dL (9.28 mmol/L).
- D Fasting serum glucose 140 mg/dL (7.8 mmol/L).
Question 83 of 130
A client is admitted to the emergency department after a motor vehicle collision. During the assessment, the nurse observes weak radial pulses, absent breath sounds unilaterally, and tracheal deviation to the right side. Which complication should the nurse suspect?
- A Flail chest.
- B Pulmonary edema.
- C Pleural effusion.
- D Tension pneumothorax.
Question 84 of 130
A client with benign prostatic hypertrophy (BPH) receives a new prescription for terazosin 1 mg PO daily. Which information should the nurse include in the teaching plan? Select all that apply.
- A Avoid prolonged exposure to sunlight.
- B Do not stop taking the medication abruptly.
- C Take the first dose at bedtime.
- D Get up slowly from a sitting position.
- E Contact the clinic if palpitations occur.
Question 85 of 130
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should1 moni2tor to assess the client’s progress. HESI Exit Q&A
Condition Summary:
A 53-year-old female presents with daily abdominal discomfort, significant weight loss (15 lbs in 3 months), and onset of tarry stools. She has been taking ibuprofen around the clock for three months and has a history of H. pylori.
Answer:
| Category | Selections |
| Potential Condition | Peptic ulcer disease |
| Actions to Take | 1. Educate client on NPO status 2. Prepare client for esophagogastroduodenoscopy (EGD) |
| Parameters to Monitor | 1. Disease complications such as hemorrhage, perforation, and obstruction 2. Laboratory values (e.g., Hgb/Hct for bleeding) |
Question 87 of 130
The nurse reviews the client’s imaging studies. Click to highlight the findings that are consistent with the client’s diagnosis of lung cancer.
Chest X-ray Report: Findings: A 4 cm irregular mass is noted in the right upper lobe. Hilar lymphadenopathy is present on the right side. Small pleural effusion noted on the right. No evidence of pneumothorax. Heart size is within normal limits.
Answer: The findings consistent with lung cancer are:
- 4 cm irregular mass is noted in the right upper lobe
- Hilar lymphadenopathy is present on the right side
- Small pleural effusion noted on the right
Question 88 of 130
The nurse evaluates the client’s understanding of the planned lobectomy. Which statement by the client indicates a need for further teaching?
- A “I will have a tube in my chest after the surgery to help drain fluid.”
- B “I should practice using my incentive spirometer before the surgery.”
- C “I will be able to get out of bed and walk the same day as my surgery.”
- D “I won’t need to worry about pain because the surgery will fix the problem.”
Question 89 of 130
A nurse is caring for a client with a history of systemic lupus erythematosus (SLE). Which clinical manifestation(s) should the nurse expect to find? Select all that apply.
- A Facial butterfly rash
- B Joint pain and swelling
- C Photosensitivity
- D Fatigue
- E Proteinuria
Answer:
- A Facial butterfly rash
- B Joint pain and swelling
- C Photosensitivity
- D Fatigue
- E Proteinuria
Question 90 of 130
A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which statement by the client indicates an understanding of the teaching?
- A “I will increase my intake of dark green leafy vegetables.”
- B “I will use a hard-bristled toothbrush to clean my teeth.”
- C “I will take aspirin if I develop a headache.”
- D “I will use an electric razor for shaving.”
Question 91 of 130
A nurse is assessing a client who is 24 hours postoperative following an abdominal surgery. Which finding should the nurse report to the provider immediately?
- A Absent bowel sounds in all four quadrants
- B Serosanguineous drainage on the surgical dressing
- C Urine output of 20 mL/hr for the past 2 hours
- D Client reports pain level of 6 on a scale of 0 to 10
Question 92 of 130
A nurse is caring for a client who is receiving a continuous intravenous infusion of heparin. Which laboratory value should the nurse monitor to evaluate the effectiveness of the therapy?
- A Prothrombin time (PT)
- B Activated partial thromboplastin time (aPTT)
- C International normalized ratio (INR)
- D Bleeding time. HESI Exit Q&A
Question 93 of 130
A nurse is assessing a client with suspected cholecystitis. Which finding(s) are characteristic of this condition? Select all that apply.
- A Right upper quadrant pain radiating to the right shoulder
- B Pain that worsens after eating a high-fat meal
- C Nausea and vomiting
- D Fever and chills
- E Positive Murphy’s sign
Question 97 of 130
The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicates to the nurse that the client understands the prescribed diet?
- A Baked potato with skin, raw carrots.
- B Pancakes, whole-grain cereals.
- C Roast pork, fresh strawberries.
- D Roasted turkey, canned vegetables.
Question 96 of 130
The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?
- A A tuna fish sandwich with chips and ice cream.
- B A peanut butter sandwich with soda and cookies.
- C Vegetable soup, crackers, and milk.
- D A salad with three kinds of lettuce and fruit.
Question 95 of 130
The plan of care for a client who was recently diagnosed with breast cancer includes the nursing problem, “Anxiety related to the threat of death secondary to the cancer diagnosis.” Which expected outcome should the nurse identify for this client?
- A Verbalizes feelings when becoming anxious.
- B Describes acceptance of impending death.
- C Uses coping mechanisms effectively.
- D Cries openly when discussing diagnosis.
Question 103 of 130
The nurse is monitoring a client with Cushing’s disease in the postanesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important for the nurse to include in the client’s plan of care (POC)?
- A Maintain nasal packing.
- B Provide frequent mouth care.
- C Monitor intake and output.
- D Keep head of bed at 30°.
Question 104 of 130
Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID 19. Which action is most important for the nurse to take? HESI Exit Q&A
- A Institute droplet precautions, place client in a private room, and keep the door closed.
- B Update the client and family regarding the COVID 19 vaccines that are available.
- C Notify the charge nurse the client will need assignment to the COVID 19 specified area of the facility.
- D Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
Question 105 of 130
When caring for a client diagnosed with pernicious anemia, the nurse recognizes that the condition is caused by the malabsorption of which vitamin?
- A Vitamin A.
- B Vitamin C.
- C Vitamin D.
- D Vitamin B₁₂.
Question 106 of 130
An older adult client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). The client has facial paralysis and cannot move the left side of the body. When entering the room, the nurse finds the client’s spouse tearful and trying unsuccessfully to give the client a drink of water. Which action should the nurse take?
- A Give the spouse a straw to help facilitate the client’s drinking.
- B Ask the spouse to stop and assess the client’s swallowing reflex.
- C Obtain thickening powder before providing any more fluids.
- D Assist the spouse and carefully give the client small sips of water.
Question 107 of 130
A client on the psychiatric unit is making sexual advances towards a nurse. Which action should this nurse implement first?
- A Document as specifically as possible the client’s behavior in the nurse’s notes.
- B Discuss with the client why the client is making sexual advances toward the nurse.
- C Tell the client in a matter-of-fact manner to stop the sexual advances.
- D Request an immediate team meeting to discuss the inappropriate behavior.
Question 124 of 130
Patient Data
- History and Physical: The client is a 36-year-old female admitted for confusion and a change in level of consciousness (LOC).
- Flow Sheet (Intake and Output):
- 1600: IV fluid intake 100 mL, Urine output 89 mL
- 1700: IV fluid intake 100 mL, Urine output 100 mL
- 1800: IV fluid intake 100 mL, Urine output 450 mL
- 1900: IV fluid intake 100 mL, Urine output 420 mL. HESI Exit Q&A
Question: Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.
The client is showing signs of Hypovolemia related to Diabetes insipidus.
Question 125 of 130
The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client’s room after taking vital signs. Which action should the nurse take?
- A Instruct the UAP to return to the client’s room to perform handwashing.
- B Supervise the UAP in the next client’s room to evaluate hand hygiene.
- C Advise the UAP to wear gloves when obtaining vital signs for all clients.
- D Remind the UAP to continue rubbing the hands together until they are dry.
Question 127 of 130
The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the UAP?
- A Remove a client’s discontinued nasogastric tube.
- B Notify the nurse of a client’s readiness for discharge.
- C Assist clients on the unit with using incentive spirometer devices.
- D Irrigate a urinary catheter with normal saline.
Question 128 of 130
When assessing cranial nerve XI function during a shoulder shrug, which action should the nurse perform to evaluate muscle strength?
- A Listen for crepitation in the joint.
- B Visually compare shoulder movement.
- C Observe accessory muscle movement.
- D Apply pressure on both shoulders. HESI Exit Q&A
Question 129 of 130
The hospice nurse is teaching the family of a client receiving palliative care at home on how to provide care. Which instruction should the nurse provide?
- A Keep mucous membranes moist.
- B Maintain in high Fowler’s position.
- C Record the client’s daily weights.
- D Report any change in urine color.
Question 130 of 130
The nurse observes an unlicensed assistive personnel (UAP) begin to remove exam gloves after emptying a bedpan containing feces. The UAP slides two fingers inside one of the gloves and begins to roll the glove off. Which action should the nurse implement?
- A Advise the UAP that the technique being used will result in hand contamination.
- B Instruct the UAP to use two pairs of gloves when fecal contamination is likely.
- C Remind the UAP to discard the gloves in the biohazard container after removal.
- D Suggest that the UAP roll both of the gloves off and inside out at the same time.
