2018 HESI EXIT V4 {100%} | ALL CORRECT ANSWERS

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2018 HESI EXIT V4 1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? A) Make certain the child is maintained i... n correct body alignment. B) Be sure the traction weights touch the end of the bed. C) Adjust the head and foot of the bed for the child's comfort D) Release the traction for 15-20 minutes every 6 hours PRN. The correct answer is A: Make certain the child is maintained in correct body alignment. 2. The nurse is assessing a healthy child at the 2 year check up. Which of the following should the nurse report immediately to the health care provider? A) Height and weight percentiles vary widely B) Growth pattern appears to have slowed C) Recumbent and standing height are different D) Short term weight changes are uneven The correct answer is A: Height and weight percentiles vary widely 3. The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse? A) Teach the parents how to perform cardiopulmonary resuscitation B) Recommend that the parents give in when he holds his breath to prevent anoxia C) Advise the parents to ignore breath holding because breathing will begin as a reflex D) Instruct the parents on how to reason with the child about possible harmful effects The correct answer is C: Advise the parents to ignore breath holding because breathing will begin as a reflex 4. The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina? A) "My pain is deep in my chest behind my sternum." B) "When I sit up the pain gets worse." C) "As I take a deep breath the pain gets worse." D) "The pain is right here in my stomach area." The correct answer is A: "My pain is deep in my chest behind my sternum." . 5. The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client's recentmemory? A) "Name the year." "What season is this?" (pause for answer after each question) B) "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to subtract 7 from the new number." C) "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen." D) "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?" The correct answer is C: "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen." 6. In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust? A) Food B) Warmth C) Security D) Comfort The correct answer is C: Security 7. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? A) "I cannot give this medication as it is written. I have no idea of what you mean." B) "Would you please clarify what you have written so I am sure I am reading it correctly?" C) "I am having difficulty reading your handwriting. It would save me time if you would be more careful." D) "Please print in the future so I do not have to spend extra time attempting to read your writing." The correct answer is B) "Would you please clarify what you have written so I am sure I am reading it correctly?" 8. What is the most important consideration when teaching parents how to reduce risks in the home? A) Age and knowledge level of the parents B) Proximity to emergency services C) Number of children in the home D) Age of children in the home The correct answer is D: Age of children in the home9. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should A) Administer a placebo B) Encourage increased fluid intake C) Administer the prescribed analgesia D) Recommend relaxation exercises for pain control The correct answer is C: Administer the prescribed analgesia 10. While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention? A) Respiratory rate of 42 B) Lethargy for the past hour C) Apical pulse of 54 D) Coughing up copious secretions The correct answer is A: Respiratory rate of 30 11. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings? A) Lethargy B) Heat intolerance C) Diarrhea D) Skin eruptions The correct answer is A: Lethargy 12. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse? A) "Do not worry. Epilepsy can be treated with medications." B) "The seizure may or may not mean your child has epilepsy." C) "Since this was the first convulsion, it may not happen again." D) "Long term treatment will prevent future seizures." The correct answer is B: "The seizure may or may not mean your child has epilepsy." 13. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies? A) Risk for injury B) Risk for knowledge deficitC) Altered thought process D) Disturbance in self-esteem The correct answer is A: Risk for injury 14. The nurse is caring for a 10 month-old infant who is has oxygen via mask. It is important for the nurse to maintain patency of which of these areas? A) Mouth B) Nasal passages C) Back of throat D) Bronchials The correct answer is B: Nasal passages 15. The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client? A) "Take at least 2 weeks off from work." B) "You will need another chest x-ray in 6 weeks." C) "Take your temperature every day." D) "Complete all of the antibiotic even if your findings decrease." The correct answer is D: "Complete all of the antibiotic even if your findings decrease." 16. When counseling a 6 year old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder? A) Has no clear etiology B) May be associated with sleep phobia C) Has a definite genetic link D) Is a sign of willful misbehavior The correct answer is A: Has no clear etiology 17. The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior? A) Reprimand the child and give a 15 minute "time out" B) Maintain a permissive attitude for this behavior C) Use patience and a sense of humor to deal with this behavior D) Assert authority over the child through limit setting The correct answer is C: Use patience and a sense of humor to deal with this behavior 18. The nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which of the following demonstrates appropriate teaching by the nurse? A) Chewable aspirin is the preferred analgesicB) Topical cortisone ointment relieves itching C) Papules, vesicles, and crusts will be present at one time D) The illness is only contagious prior to lesion eruption The correct answer is C: Papules, vesicles, and crusts will be present at one time 19. The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first? A) Take the client's vital signs B) Place the client in a sitting position with legs dangling C) Contact the health care provider D) Administer the PRN anti anxiety agent The correct answer is B: Place the client in a sitting position with legs dangling 20. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to A) Dress the child warmly to avoid chilling B) Keep the child away from other children for the duration of the rash C) Clean the affected areas with tepid water and detergent D) Wrap the child's hand in mittens or socks to prevent scratching The correct answer is D: Wrap the child''s hand in mittens or socks to prevent scratching 21. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special family gatherings?" Which initial response by the nurse would be best? A) "A recovering person has to be very careful not to lose control, therefore, confine your drinking just at family gatherings." B) "At your next AA meeting discuss the possibility of limited drinking with your sponsor." C) "A recovering person needs to get in touch with their feelings. Do you want a drink?" D) "A recovering person cannot return to drinking without starting the addiction process over." The correct answer is D: "The recovering person cannot return to drinking without starting the addiction process over." 22. In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding? A) Age 40 years B) Lactose intoleranceC) Family history of breast cancer D) Uses cocaine on weekends The correct answer is D: Uses cocaine on weekends 23. A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this medication? A) Potassium B) Arterial blood gasses C) Blood urea nitrogen D) Thiocyanate The correct answer is D: Thiocyanate 24. A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond? A) With acceptance and views the victim’s comment as an indication that their marriage is in trouble B) With fear of rejection causing increased rage toward the victim C) With a new commitment to seek counseling to assist with their marital problems D) With relief, and welcomes the separation as a means to have some personal time The correct answer is B: With fear of rejection causing increased rage toward the victim 25. A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus? A) Discuss with the mother sharing parenting responsibilities B) Set time aside to get the mother to express her feelings and concerns C) Arrange for the parents to attend infant care classes D) Talk with the father and help him accept the wife's decision The correct answer is B: Set time aside to get the mother to express her feelings and concerns 26. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client A) Eat foods high in sodium increases sputum liquefaction B) Use oxygen during meals improves gas exchange C) Perform exercise after respiratory therapy enhances appetite D) Cleanse the mouth of dried secretions reduces risk of infectionThe correct answer is B: Use oxygen during meals improves gas exchange 27. Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis? A) I noticed a little lump a little above the belly button. B) The baby seems hungry all the time. C) Mild vomiting that progressed to vomiting shooting across the room. D) Irritation and spitting up immediately after feedings. The correct answer is C: Mild emesis progressing to projectile vomiting 28. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings? A) Decreased cardiac output B) Tissue hypoxia C) Cerebral edema D) Reduced oxygen saturation The correct answer is B: Tissue hypoxia 29. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet A) High in carbohydrates and proteins B) Low in carbohydrates and proteins C) High in carbohydrates, low in proteins D) Low in carbohydrates, high in proteins The correct answer is A: High in carbohydrates and proteins 30. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant? A) Increased 10% in height B) 2 deciduous teeth C) Tripled the birth weight D) Head > chest circumference The correct answer is C: Tripled the birth weight- -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - 135. Parents of a 7 year-old child call the clinic nurse because their daughter was sent home from school because of a rash. The child had been seen the day before by the health care provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most appropriate action by the nurse? A) Tell the parents to bring the child to the clinic for further evaluation B) Refer the school officials to printed materials about this viral illness C) Inform the teacher that the child is receiving antibiotics for the rash D) Explain that this rash is not contagious and does not require isolation The correct answer is D: Explain that this rash is not contagious and does not require isolation 136. When making a home visit to a client with chronic pyelonephritis, which nursing action has the highest priority? A) Follow-up on lab values before the visit B) Observe client findings for the effectiveness of antibiotics C) Ask for a log of urinary output D) As for the log of the oral intake The correct answer is C: Ask for a log of urinary output 137. The nurse is caring for a newborn who has just been diagnosed with hypospadias. After discussing the defect with the parents, the nurse should expect that A) Circumcision can be performed at any time B) Initial repair is delayed until ages 6-8 C) Post-operative appearance will be normal D) Surgery will be performed in stages The correct answer is D: Surgery will be performed in stages 138. The nurse is assessing a client on admission to a community mental health center. The client discloses that she has been thinking about ending her life. The nurse's best response would be A) "Do you want to discuss this with your pastor?" B) "We will help you deal with those thoughts." C) "Is your life so terrible that you want to end it?" D) "Have you thought about how you would do it?" The correct answer is D: "Have you thought about how you would do it?"139. The nursing care plan for a client with decreased adrenal function should include A) Encouraging activity B) Placing client in reverse isolation C) Limiting visitors D) Measures to prevent constipation The correct answer is C: Limiting visitors 140. The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care? A) Cough and deep breathe every 2 hours B) Place the client in contact isolation C) Provide a diet high in protein D) Institute seizure precautions The correct answer is A: Cough and deep breathe every 2 hours 141. Which of the following conditions assessed by the nurse would contraindicate the use of benztropine (Cogentin)? A) Neuromalignant syndrome B) Acute extrapyramidal syndrome C) Glaucoma, prostatic hypertrophy D) Parkinson's disease, atypical tremors The correct answer is C: Glaucoma, prostatic hypertrophy 142. The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first? A) Perform defibrillation B) Administer epinephrine as ordered C) Assess for presence of pulse D) Institute CPR The correct answer is C: Assess for presence of pulse 143. During the use of an interpreter to teach a client about a procedure to do in the home the nurse should take which approach? A) Speak directly to the interpreter while presenting information and use pauses for questions B) Talk to the interpreter in advance and leave the client and interpreter aloneC) Include a family member and direct communications to that person D) Face the client while presenting the information as the interpreter talks in the native language The correct answer is D: Face the client while presenting the information as the interpreter talks in the native language . 144. A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority? A) Counsel the woman to consent to HIV screening B) Perform tests for sexually transmitted diseases C) Discuss her high risk for cervical cancer D) Refer the client to a family planning clinic The correct answer is A: Counsel the woman to consent to HIV screening 145. A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions? A) High Fowler's B) Supine C) Left lateral D) Low Fowler's The correct answer is A: High Fowler''s 146. A nurse who is evaluating a mentally retarded 2 year-old in a clinic should stress which goal when talking to the child's mother? A) Teaching the child self care skills B) Preparing for independent toielting C) Promoting the child's optimal development D) Helping the family decide on long term care The correct answer is C: Promoting the child''s optimal development 147. The nurse is caring for a client with trigeminal neuralgia (tic douloureaux). To assist the client with nutrition needs, the nurse should A) Offer small meals of high calorie soft food B) Assist the client to sit in a chair for meals C) Provide additional servings of fruits and raw vegetables D) Encourage the client to eat fish, liver and chicken The correct answer is A: Offer small meals of high calorie soft food148. The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart disease. Which of these is most likely to be seen with this diagnosis? A) Several otitis media episodes in the last year B) Weight and height in 10th percentile since birth C) Takes frequent rest periods while playing D) Changing food preferences and dislikes The correct answer is C: Takes frequent rest periods while playing 149. The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is A) Urinary output of 30 ml per hour B) No complaints of thirst C) Increased hematocrit D) Good skin turgor around burn The correct answer is A: Urinary output of 30 ml per hour 150. Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which of the following conditions would most likely explain these findings? A) Ingestion of tetracycline B) Excessive fluoride intake C) Oral iron therapy D) Poor dental hygiene The correct answer is B: Excessive fluoride intake 151. The nurse is reassigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice? A) An 18 month-old who ate an undetermined amount of crystal drain cleaner B) A 14 month-old who chewed 2 leaves of a philodendron plant C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium) D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid The correct answer is A: An 18 month-old who ate an undetermined amount of crystal drain cleaner152. Which of these is an example of a variation in the newborn resulting from the presence of maternal hormones? A) Engorgement of the breasts B) Mongolian spots C) Edema of the scrotum D) Lanugo The correct answer is A: Engorgement of the breasts 153. A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse? A) Elbow B) Mummy C) Jacket D) Clove hitch The correct answer is A: Elbow 154. A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The first nursing action should be to A) Notify the health care provider immediately B) Suggest in-patient psychiatric care C) Respect the client's confidential disclosure D) Phone the family to warn them of the risk The correct answer is A: Notify the health care provider immediately 155. A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care? A) Altered nutrition: less than body requirements B) Potential complication hemorrhage C) Ineffective individual coping D) Fluid volume excess The correct answer is B: Potential complication hemorrhage 156. While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior? A) Strange bed and surroundings B) Separation from parents C) Presence of other toddlersD) Unfamiliar toys and games The correct answer is B: Separation from parents 157. Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)? A) Direct sunlight B) Foods containing tyramine C) Foods fermented with yeast D) Canned citrus fruit drinks The correct answer is A: Avoid direct sunlight 158. The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is A) "You think that someone wants to poison you?" B) "Why do you think the food is poisoned?" C) "These feelings are a symptom of your illness." D) "You’re safe here. I won’t let anyone poison you." The correct answer is A: "You think that someone wants to poison you?" 159. The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that A) The client should remain on bed rest in a semi-Fowler's position B) The client should alternate ambulation with bed rest with legs elevated C) The client may ambulate and sit in chair as tolerated D) The client may ambulate as tolerated and remain in semi-Fowler position in bed The correct answer is B: The client should alternate ambulation with bed rest with legs elevated 160. The nurse is performing physical assessments on adolescents. When would the nurse anticipate that females experience growth spurts? A) About 2 years earlier than males B) About the same time as males C) Just prior to the onset of puberty D) That increase height by 4 inches each year The correct answer is A: About 2 years earlier than males [Show More]

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