Question 9
HESI Exit Exam. A client with advanced Parkinson’s disease receives a prescription for apomorphine hydrochloride 3 mg subcutaneously. The medication is available in a 30 mg/mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
- 0.1
- 0.3
- 1.0
- 3.0
Answer: 0.1 (Note: Calculation based on 30 mg per 1 mL concentration)
Question 10
A young adult male client is admitted to the emergency department (ED) following a motor vehicle collision and the nurse suspects that he has suffered a spinal cord injury (SCI). Which assessment finding, if present, will alert the nurse to suspect spinal shock?
- A Dilated pupils.
- B Absence of reflexes.
- C Tachycardia.
- D Hypertension.
Answer: B. Absence of reflexes.
Question 11
Following a motorcycle vehicle collision, an adult client can follow simple commands, but is oriented only to self. The client was not wearing a helmet at the time of the accident, and is exhibiting periorbital bruising with bloody drainage from both ears. Which assessment finding should the nurse identify as a life threatening condition? HESI Exit Exam
- A Rib pain with deep inspiration.
- B Generalized abdominal tenderness.
- C Nausea with projectile vomiting.
- D Diminished bilateral breath sounds.
Answer: D. Diminished bilateral breath sounds.
Question 12 (Part 1)
The primary nurse reviews the client’s history and vital signs. Select the 3 priority assessment findings that require immediate follow up.
- A Pulsatile mass
- B Liquid diarrhea
- C Extremity pulse 2+
- D Tiredness
- E Indigestion
- F Abdominal bruit
- G Pain level in abdomen and back
Answer: A, F, and G.
Question 12 (Part 2)
Complete the table to indicate which assessment findings are consistent with the disease process for an aortic aneurysm or gastric cancer.
- Pulsatile mass: Aortic Aneurysm
- Indigestion: Gastric Cancer
- Fatigue: Gastric Cancer
- Auscultation of bruit: Aortic Aneurysm
- Back pain: Aortic Aneurysm
- Feeling of fullness: Gastric Cancer
Question 12 (Part 3)
Select the words from the choices below to fill in the blanks. The nurse recognizes that the client is most at risk for aneurysm _____. The risk for this complication is highest in individuals with a history of _____.
- Rupture
- Dissection
- Hypertension
- Smoking
Answer: Rupture; Smoking.
Question 12 (Part 4)
The nurse reviews the orders for the client and determines which interventions are indicated or contraindicated.
- Document any skin lesions on lower legs: Indicated
- Place client on 2 L/minute oxygen: Indicated
- Start 0.9% sodium chloride fluid bolus: Indicated
- Insert indwelling urinary catheter: Indicated
- Mark pedal pulse sites with a single use marker: Indicated
- Ensure surgical consent has been completed: Indicated
Question 12 (Part 5)
Which modifiable risk factors should the nurse include in the teaching plan for this client? (Select all that apply.)
- A Male gender
- B Age
- C Obesity
- D Coronary artery disease
- E High cholesterol
- F Hypertension
- G Family history
- H Tobacco use
Answer: C, E, F, and H.
Question 12 (Part 6)
The nurse reassesses the client for discharge readiness. Which finding(s) indicate the client is ready for home discharge? (Select all that apply.)
- Pedal pulse of 2+ or better
- Blood pressure of 120/74 mmHg
- Client has urine output of 1,600 mL in 24 hours
- Creatinine of 1.2 mg/dL (106 mmol/L)
- Absence of numbness or tingling in feet
Answer: All of the above.
Question 13
Which site is most appropriate for the nurse to inspect for petechiae in a dark-skinned client?
- A. The earlobes.
- B. The palms of the hands.
- C. The nail beds.
- D. The soles of the feet.
Question 14
A client is admitted to the emergency department with suspected meningitis. Which action should the nurse take first?
- A. Place the client in a private room.
- B. Obtain a sputum culture.
- C. Administer an analgesic for headache.
- D. Perform a neurological assessment.
Question 15
Which nursing diagnosis has the highest priority for a client with acute leukemia?
- A. Fatigue related to anemia.
- B. Risk for injury related to thrombocytopenia.
- C. Altered nutrition: less than body requirements.
- D. Impaired physical mobility.
Question 16
A young adult is diagnosed with Hodgkin’s lymphoma. Which nursing diagnosis is most likely to be a priority for this client? HESI Exit Exam
- A. Impaired skin integrity.
- B. Anticipatory grieving related to diagnosis.
- C. Knowledge deficit regarding treatment.
- D. Risk for infection.
Question 17
A client is receiving treatment for idiopathic thrombocytopenic purpura (ITP). Which laboratory value should the nurse monitor to determine the effectiveness of the treatment?
- A. Platelet count.
- B. White blood cell count.
- C. Hemoglobin level.
- D. Prothrombin time (PT).
Question 18
A client with a history of chronic alcoholism is admitted with a platelet count of 80,000/mm³. Which intervention should the nurse include in the client’s plan of care?
- A. Bleeding precautions.
- B. High-protein diet.
- C. Fluid restriction.
- D. Seizure precautions.
Question 19
A client returns to the unit following a transsphenoidal hypophysectomy. Which assessment finding should the nurse report to the healthcare provider immediately?
- A. Nasal packing saturated with serosanguinous drainage.
- B. Complaint of a dry mouth.
- C. Check the specific gravity of the urine.
- D. Temperature of 99.2° F.
Question 20
The nurse is unable to read the healthcare provider’s handwriting for a newly prescribed medication. Which action should the nurse take?
- A. Ask another nurse to help interpret the order.
- B. “Would you please clarify what you have written so I am sure I am reading it correctly?”
- C. Contact the pharmacist for clarification.
- D. Transcribe the order as it appears and clarify later.
Question 18
A female client is brought to the emergency department (ED) after a motor vehicle collision (MVC) in which she bumped her head on the dashboard. The client is confused and restless. Which intervention is most important for the nurse to implement?
- Assess for drainage from ears or nose.
- Implement seizure precautions.
- Orient the client to her surroundings.
- Allow husband to stay at bedside.
Question 19
A client who has been sedated and on a mechanical ventilator for 6 days is extubated and placed on a face mask. When the nurse offers a sip of water, the client begins coughing, as if the airway is restricted. The client’s spouse is at the bedside and is concerned because the client has a very sore throat. Which intervention is most important for the nurse to implement?
- Elevate the head of his bed at least 45 degrees.
- Hold oral intake until swallow evaluation is done.
- Titrate the oxygen to keep saturation above 92%.
- Administer PRN IV pain medication.
Question 20
A client is brought to the emergency department (ED) after falling out of a tree. Which finding warrants immediate intervention by the nurse?
- Clear fluid leaking from the nose.
- Troubled with a severe headache.
- Periorbital ecchymosis of right eye.
- Sluggish pupillary response to light.
Question 21
A client with a spinal cord injury has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client’s plan of care (POC)? HESI Exit Exam
- Explain the need to limit intake of oral fluids to reduce client discomfort.
- Teach the client techniques for performing intermittent catheterization.
- Provide a bedside commode for immediate use in the client’s room.
- Remind the client to practice pelvic floor (Kegel) exercises regularly.
Question 22 (Case Study: CP Client)
The nurse identifies that the client has a pleural effusion. Which additional assessment findings are consistent with a pleural effusion? Select all that apply.
- Decreased chest rise on the right side
- Expiratory sibilant wheezes
- Asymmetric thoracic expansion
- Blood in sputum
- Dullness to percussion in the right lower lobe
- Crackles and/or rhonchi throughout the lung fields
Question 23 (Case Study: CP Client)
Which clinical manifestations are contraindications for a thoracentesis? Select all that apply.
- Hypertension
- Unstable hemodynamics
- Infection
- Coagulation deficiencies
- Mechanical ventilation required
- Tracheal deviation
Question 24 (Case Study: CP Client)
Complete the following sentence by choosing from the lists of options.
The client likely has a(n) Traumatic iatrogenic pneumothorax caused by Thoracentesis. HESI Exit Exam
Question 25 (Case Study: CP Client)
Which 4 actions should the nurse perform immediately?
- Call for a stat chest x-ray
- Increase the client’s oxygen
- Place the client on a continuous pulse oximeter
- Replace the tracheostomy tube
- Suction the client
- Collect supplies for a chest tube
Question 26 (Case Study: CP Client)
A chest tube is placed. Which monitoring parameters are important for the nurse to include in the plan of care? Select all that apply.
- Peak flow meter values
- Daily weights
- Developmentally appropriate pain rating
- Chest circumference
- Arterial blood gas (ABG) results
- Bubbling in the water seal chamber
Question 27 (Case Study: CP Client)
For each short-term goal, click to specify the intervention that should be implemented.
- Prevent desaturation: Avoid sedation
- Promote secretion clearance: Increase the flow rate of oxygen
- Prevent infection: Perform proper hand hygiene
Question 28
After several days of sedation and mechanical ventilation, a client is successfully extubated and is placed on oxygen 40% by face mask. While making rounds, the nurse finds that the client is confused and is attempting to get out of bed. Vital signs are temperature $99.2^\circ \text{F}$ ($37.3^\circ \text{C}$), heart rate 112 beats/minute, respirations 16 breaths/minute, blood pressure 100/70, and oxygen saturation 98%. Which action should the nurse take?
- Increase the oxygen to 50% by face mask.
- Notify the Rapid Response Team (RRT).
- Apply wrist restraints.
- Administer a benzodiazepine for restlessness.
Question 47
Which data, obtained during an admission interview of a 45-year-old female client, should lead the nurse to question the administration of the benzodiazepine alprazolam?
- A. Tells the nurse that she might be pregnant.
- B. Has a history of heart failure (HF).
- C. Smokes 3 packs of cigarettes/day.
- D. Has a severe panic disorder.
Question 48
A client with obsessive-compulsive disorder (OCD) who receives a new prescription for venlafaxine. Which finding indicates the nurse that the client is experiencing a therapeutic response to the medication?
- A. Ability to feel remorse after doing a compulsive act.
- B. A more organized thought process.
- C. Feeling less depressed and suicidal.
- D. Reduction in the amount of compulsive activity.
Question 49
The healthcare provider (HCP) prescribes the antibiotic tetracycline HCl for an adult client that arrived at an outpatient clinic. Which instruction should the nurse include in the teaching plan for this client?
- A. Take the medication with a glass of milk.
- B. Protect the skin from sunlight while taking the drug.
- C. Do not take the medication with food.
- D. Use an antacid if gastrointestinal distress occurs.
Question 50
The healthcare provider (HCP) prescribes pseudoephedrine to a client with nasal decongestion. Which statement provided by the client requires additional instruction by the nurse?
- A. “I should not take this with my MAO inhibitor.”
- B. “Take the medication an hour before bedtime.”
- C. “I will call the HCP if I feel my heart racing.”
- D. “I can use hard candy to relieve my dry mouth.”
Question 51
A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?
- A. Notify your healthcare provider immediately if involuntary movements develop.
- B. Use a sunscreen when being outdoors in the sun.
- C. Drink at least 8 glasses of water every day.
- D. This drug may cause your urine to turn pink or orange.
Question 52
The nurse is admitting a client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider (HCP) immediately?
- A. Weight gain of 5 pounds (2.27 kg) in the last six months.
- B. Nausea and vomiting.
- C. Depressed affect and lack of energy.
- D. Short-term memory loss.
Question 53
The nurse is assessing a client who is receiving furosemide 40 mg PO daily. Which statement by the client is likely to indicate that the client is experiencing a side effect of the drug?
- A. “I am so glad the swelling in my ankles is going down.”
- B. “I find that I am urinating more frequently than I used to.”
- C. “I have noticed a yellow haze and halos around lights.”
- D. “These muscle cramps in my legs are really bothersome and uncomfortable.”
Question 54
The nurse is providing discharge instructions for a client with metastatic cancer who is prescribed morphine for bone pain. Which information from the client indicates to the nurse an understanding of the medication?
- A. Observe bowel movement pattern and take a stool softener.
- B. Take alprazolam at the same time for increased pain relief.
- C. Avoid drinking grapefruit juice when taking this medication.
- D. Notify the healthcare provider (HCP) if agitation or insomnia occurs.
Question 55
The nurse is assessing a preoperative client who takes phenelzine. Which of the following is most important for the nurse to monitor for this client?
- A. Respiratory rate.
- B. Body temperature.
- C. Blood pressure.
- D. Urine output.
Question 56
A client who is experiencing pain is being assessed by the nurse. Which of the following is the most important for the nurse to perform?
- A. Observe the client’s facial expressions and body language.
- B. Ask the client to describe the intensity of the pain being experienced.
- C. Assess the client’s vital signs, especially heart rate and blood pressure.
- D. Determine the effectiveness of the previous pain medication given.
