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 4year-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...
HESI Exit V2 Exam
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 4year-
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."
2. Upon completing the admission documents, the nurse learns that the87 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
3. A nurse administers the influenza vaccine to a client in a clinic. Within15 minutes after the immunization was given, the client complains of itchy and
watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to
A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered
4. Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category?
A) An infant with intermittent bulging anterior fontanel between crying episodes
B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
D) A school-age child with singed eyebrows and hair on the arms
5. When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse’s best
action is to
A) Change whichever item is incorrect to the correct information
B) Use the bracelet and admission form until a replacement is supplied
C) Notify the admissions office and wait to apply the bracelet
D) Make a corrected identification bracelet for the client
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6. The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken?
A) Leave the order for the oncoming staff to follow-up
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification
7. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by
the nurse is to:
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) open the client's airway
8. A client has an order for 1000 ml of D5W over an 8-hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing
action?
A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs
9. Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
A) 16-year-old who had an open reduction of a fractured wrist 10hours ago
B) 20-year-old in skeletal traction for 2 weeks since a motor cycle accident
C) 72-year-old recovering from surgery after a hip replacement 2hours ago
D) 75-year-old who is in skin traction prior to planned hip pinning surgery.
10. A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member
pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side
and the client did this. What is the appropriate comment for the nurse to make?
A) Why don’t we now have the client turn back to the left side.
B) That was done correctly. Did you have any problems with the insertion?
C) Let’s check to see if the suppository is in far enough.
D) Did you feel any stool in the intestinal tract?
11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus(MRSA) has died. Which type of precautions is the appropriate type to use when
performing postmortem care?
A) airborne precautions
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B) droplet precautions
C) contact precautions
D) compromised host precautions
12. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching?
A) Void a little, clean the meatus, then collect specimen
B) clean the meatus, begin voiding, then catch urine stream
C) Clean the meatus, then urinate into container
D) Void continuously and catch some of the urine
13. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40mg every day. Which of these foods would the nurse reinforce for the client to eat at
least daily?
A) spaghetti
B) watermelon
C) chicken
D) tomatoes
14. A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse takes?
A) Look up the policy on needle sticks
B) Contact employee health services
C) Immediately wash the hands with vigor
D) Notify the supervisor and risk management
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15. As the nurse observes the student nurse during the administration of narcotic analgesic IM injection, the nurse notes that the student begins to give the
medication without first aspirating. What should the nurse do?
A) Ask the student: "What did you forget to do?”
B) Stop. Tell me why aspiration is needed.
C) Loudly state: “You forgot to aspirate.”
D) Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.”
16. A client with Guillain Barre is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most
accurately describe the client's condition?
A) Comatose, breathing unlabored
B) Glasgow Coma Scale 8, respirations regular
C) Appears to be sleeping, vital signs stable
D) Glasgow Coma Scale 13, no ventilator required
17. A client enters the emergency department unconscious via ambulance from the client’s work place. What document should be given priority to guide the
direction of care for this client?
A) The statement of client rights and the client self determination act
B) Orders written by the health care provider
C) A notarized original of advance directives brought in by the partner
D) The clinical pathway protocol of the agency and the emergency department
18. The charge nurse has a health care team that consists of 1 PN, 1unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment
should be questioned by the nurse manager?
A) An admission at the change of shifts with atrial fibrillation and heart failure - PN
B) Client who had a major stroke 6 days ago - PN nursing student
C) A child with burns who has packed cells and albumin IV running -charge nurse
D) An elderly client who had a myocardial infarction a week ago - UAP
19. A mother brings her 3-month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects
to find which of the following on the initial history and physical assessment?
A) Increased temperature and lethargy
B) Restlessness and increased mucus production
C) Increased sleeping and listlessness
D) Diarrhea and poor skin turgor
20. As the nurse takes a history of a 3-year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis?
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