2020 Hesi exit v 2
1. The nurse knows that which statement by the mother indicates that the mother
understands safety precautions with her four month-old infant and her 4 year-old child?
A) "I strap the infant car seat on the front seat to face backwards."
B) "I place my infant in the middl...
a nurse is providing care to a 17 year old client in the post operative care unit pacu after an emergency appendectomy which finding is an early indication that the
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2020 Hesi exit v 2
1. The nurse knows that which statement by the mother indicates that the mother
understands safety precautions with her four month-old infant and her 4 year-old child?
A) "I strap the infant car seat on the front seat to face backwards."
B) "I place my infant in the middle of the living room floor on a blanket to play with my
4 year old while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air
while the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen
while I make supper." - D
154. A nurse is providing care to a 17 year-old client in the post-operative care unit
(PACU) after an emergency appendectomy. Which finding is an early indication that the
client is experiencing poor oxygenation?
A) Abnormal breath sounds
B) Cyanosis of the lips
C) Increasing pulse rate
D) Pulse oximeter reading of 92% - C
149. A nurse entering the room of a postpartum mother observes the baby lying at the
edge of the bed while the woman sits in a chair. The mother states," This is not my
baby,
and I do not want it." The
nurse's best response is
A) "This is a common occurrence after birth, but you will come to accept the baby."
B) "Many women have postpartum blues and need some time to love the baby."
C) "What a beautiful baby! Her eyes are just like yours."
D) "You seem upset; tell me what the pregnancy and birth were like for you." - D
150. Which of the following times is a depressed client at highest risk for attempting
suicide?
A) Immediately after admission, during one-to-one observation
B) 7 to 14 days after initiation of antidepressant medication and psychotherapy
C) Following an angry outburst with family
D) When the client is removed from the security room - B
151. A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to
discuss the problem. What information is most important for the nurse to ask about at
this
time?
A) What are you taking for pain and does it provide total relief?
,B) What does the skin on the testicles look and feel like?
C) Do you have any questions about your care?
D) Did you know a consequence of epididymitis is infertility? - B
152. A client has had heart failure. Which intervention is most important for the nurse to
implement prior to the initial administration of Digoxin to this client?
A) Assess the apical pulse, counting for a full 60 seconds
B) Take a radial pulse, counting for a full 60 seconds
C) Use the pulse reading from the electronic blood pressure device
D) Check for a pulse deficit - A
153. A client is admitted with a tentative diagnosis of congestive heart failure. Which of
the following assessments would the nurse expect to be consistent with this problem?
A) Chest pain
B) Pallor
C) Inspiratory crackles
D) Heart murmur - C
156. A client who was medicated with meperidine hydrochloride (Demerol) 100 mg and
hydroxyzine hydrochloride (Vistaril Intramuscular) 50 mg IM for pain related to a
fractured lower right leg 1 hour ago reports that the pain is getting worse. The nurse
should recognize that the client may be developing which complication?
A) Acute compartment syndrome
B) Thromboemolitic complications
C) Fatty embolism
D) Osteomyelitis - A
155. Which order can be associated with the prevention of atelectasis and pneumonia in
a
client with amyotrophic lateral sclerosis?
A) Active and passive range of motion exercises twice a day
B) Every 4 hours incentive spirometer
C) Chest physiotherapy twice a day
D) Repositioning every 2 hours around the clock - C
157. The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which
statement from the mother supports the presence of this problem?
A) When I put my finger in the left hand the baby doesn't respond with a grasp.
B) My baby doesn't seem to follow when I shake toys in front of the face.
C) When it thundered loudly last night the baby didn't even jump.
D) When I put the baby in a back lying position that's how I find the baby. - D
158. Which statements by the client would indicate to the nurse an understanding of the
issues with end stage renal disease?
A) I have to go at intervals for epoetin (Procrit) injections at the health department.
B) I know I have a high risk of clot formation since my blood is thick from too many red
, cells.
C) I expect to have periods of little water with voiding and then sometimes to have a lot
of water.
D) My bones will be stronger with this disease since I will have higher calcium than
normal. - A
159. The nurse is caring for a client with uncontrolled hypertension. Which findings
require priority nursing action?
A) Lower extremity pitting edema
B) Rales
C) Jugular vein distension
D) Weakness in left arm - D
132. What assessment data should the nurse obtain next?
A) Status of the eyes and the tongue
B) Description of play activity
C) History of fluid intake
D) Dietary patterns - A
2. Upon completing the admission documents, the nurse learns that the 87 year-old
client
does not have an advance directive. What action should the nurse take?
A) Record the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
D) Refer this issue to the unit secretary - B
100. The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the
following lab reports should the nurse review first?
A) Protime (PT) and partial thromboplastin time (PTT)
B) Red blood cell and white blood cell counts
C) Blood urea nitrogen and creatinine clearance
D) Liver enzymes (AST and ALT) - D
110. A client has returned to the unit following a renal biopsy. Which of the following
nursing interventions is appropriate?
A) Ambulate the client 4 hours after procedure
B) Maintain client on NPO status for 24 hours
C) Monitor vital signs
D) Change dressing every 8 hours - C
109. During the check up of a 2 month-old infant at a well baby clinic, the mother
expresses concern to the nurse because a flat pink birthmark on the baby's forehead
and
eyelid has not gone away. What is an appropriate response by the nurse?
A) "Mongolian spots are a normal finding in dark-skinned children."
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