2018 HESI EXIT V5 {100%} | ALL CORRECT ANSWERS

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2018 HESI EXIT V5 1. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis? A) Nutrition B) Elimination C) Activi... ty D) Safety The correct answer is D: Safety 2. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age? A) They are able to make simple association of ideas B) They are able to think logically in organizing facts C) Interpretation of events originate from their own perspective D) Conclusions are based on previous experiences The correct answer is B: Think logically in organizing facts 3. The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse do first? A) Clear the area of any hazards B) Place the child on the side C) Restrain the child D) Give the prescribed anticonvulsant The correct answer is B: Place the child on the side 4. The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to A) Reports of difficulty falling and staying asleep B) Expression of persistent suicidal thoughts C) Lack of enjoyment in usual pleasures D) Reduced senses of taste and smell The correct answer is C: Lack of enjoyment in usual pleasures 5. A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to A) Administer pain medication B) Suction excessive tracheobronchial secretions C) Assist client to turn, deep breathe and coughD) Monitor oxygen saturation The correct answer is B: Suction excessive tracheobronchial secretions 6. While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client? A) Compulsive behavior B) Sense of impending doom C) Fear of flying D) Predictable episodes The correct answer is B: Sense of impending doom 7. A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse? A) Arrange to change client care assignments B) Explain that this behavior is expected C) Discuss the appropriate use of "time-out" D) Explain that the child needs extra attention The correct answer is B: Explain that this behavior is expected 8. A 15 year-old client with a lengthy confining illness is at risk for altered growth and development of which task? A) Loss of control B) Insecurity C) Dependence D) Lack of trust The correct answer is C: Dependence 9. Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children? A) Sports and games with rules B) Finger paints and water play C) "Dress-up" clothes and props D) Chess and television programs The correct answer is A: Sports and games with rules 10. The nurse is discussing dietary intake with an adolescent who has acne. The mostappropriate statement for the nurse is A) "Eat a balanced diet for your age." B) "Increase your intake of protein and Vitamin A." C) "Decrease fatty foods from your diet." D) "Do not use caffeine in any form, including chocolate." The correct answer is A: "Eat a balanced diet for your age." 11. The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds A) "The complaints of at least 3 common findings." B) "The absence of any opportunistic infection." C) "CD4 lymphocyte count is less than 200." D) "Developmental delays in children." The correct answer is C: "CD4 lymphocyte count is less than 200." 12. The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate? A) Offer ice cream every 2 hours B) Place the child in a supine position C) Allow the child to drink through a straw D) Observe swallowing patterns The correct answer is D: Observe swallowing patterns 13. A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize? A) Acceptance of the pregnancy B) Focus on fetal development C) Anticipation of the birth D) Ambivalence about pregnancy The correct answer is C: Anticipation of the birth 14. The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions? A) Administration of cough suppressants B) Increasing oral fluid intake to 3000 cc per day C) Maintaining bed rest with bathroom privileges D) Performing chest physiotherapy twice a dayThe correct answer is B: Increasing oral fluid intake to 3000 cc per day 15. The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up? A) A 13 month-old unable to walk B) A 20 month-old only using 2 and 3 word sentences C) A 24 month-old who cries during examination D) A 30 month-old only drinking from a sip cup The correct answer is D: A 30 month-old only drinking from a sip cup 16. Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes? A) Give written pre and post tests B) Ask questions during practice C) Allow another diabetic to assist D) Observe a return demonstration The correct answer is D: Observe a return demonstration 17. A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority? A) Elevate leg on 2 pillows B) Apply support stockings C) Apply warm compresses D) Maintain complete bed rest The correct answer is A: Elevate leg on 2 pillows 18. A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child? A) Congenital cardiac defects B) An acute febrile illness C) Prolonged hypoxemia D) Severe multiple trauma The correct answer is C: Prolonged hypoxemia 19. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer theclient to A) A social worker from the local hospital B) An occupational therapist from the community center C) A physical therapist from the rehabilitation agency D) Another client with diabetes mellitus and takes insulin The correct answer is B: An occupational therapist from the community center 20. A priority goal of involuntary hospitalization of the severely mentally ill client is A) Re-orientation to reality B) Elimination of symptoms C) Protection from harm to self or others The correct answer is C: Protection from self harm and harm to others 21. The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend A) Isometric B) Range of motion C) Aerobic D) Isotonic The correct answer is A: Isometric 22. The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report A) Loss of consciousness B) Feeding problems C) Poor weight gain D) Fatigue with crying The correct answer is A: Loss of consciousness 23. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would A) Instruct the client to maintain a regular diet the day prior to the examination B) Restrict the client's fluid intake 4 hours prior to the examination C) Administer a laxative to the client the evening before the examination D) Inform the client that only 1 x-ray of his abdomen is necessary The correct answer is C: Administer a laxative to the client the evening before the examination24. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time? A) Altered tissue perfusion B) Risk for fluid volume deficit C) High risk for hemorrhage D) Risk for infection The correct answer is D: Risk for infection 25. The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that A) Circumcision is delayed so the foreskin can be used for the surgical repair B) This procedure is contraindicated because of the permanent defect C) There is no medical indication for performing a circumcision on any child D) The procedure should be performed as soon as the infant is stable The correct answer is A: Circumcision is delayed so the foreskin can be used for the surgical repair 26. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect? A) Confusion B) Loss of half of visual field C) Shallow respirations D) Tonic-clonic seizures The correct answer is C: Shallow respirations 27. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse’s best explanation of these findings? A) These side effects are common and should subside in a few days B) The client is probably having an allergic reaction and should discontinue the drug C) Taking the lithium on an empty stomach should decrease these symptoms D) Decreasing dietary intake of sodium and fluids should minimize the side effects The correct answer is A: These side effects are common and should subside in a few days 28. A 57 year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse?A) Ask the client if he has noticed any bleeding or dark stools B) Tell the client to call 911 and go to the emergency department immediately C) Schedule a repeat Hemoglobin and Hematocrit in 1 month D) Tell the client to schedule an appointment with a hematologist The correct answer is A: Ask the client if he has noticed any bleeding or dark stools 29. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the A) Surgical repair of a diseased coronary artery B) Placement of an automatic internal cardiac defibrillator C) Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow D) Non-invasive radiographic examination of the heart The correct answer is C: Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow 30. For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate? A) Institute seizure precautions B) Weigh the child twice per shift C) Encourage the child to eat protein-rich foods D) Relieve boredom through physical activity The correct answer is A: Institute seizure precautions 31. Following mitral valve replacement surgery a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc’s of D5W. The infusion pump delivers 60 micro drops/cc. What rate would deliver 4 mgm of Lidocaine/ minute? A) 60 microdrops/minute B) 20 microdrops/minute C) 30 microdrops/minute D) 40 microdrops/minute The correct answer is A: 60 microdrops/minute 2 gm=2000 mgm 2000 mgm/500 cc = 4 mgm/x cc 2000x = 2000x= 2000/2000 = 1 cc of IV solution/minute CC x 60 microdrops = 60 microdrops/minute 32. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first? A) Review the client's weight pattern over the year B) Ask the mother to record her diet for the last 24 hours C) Encourage her to talk about her view of herself D) Give her several pamphlets on postpartum nutrition The correct answer is C: Encourage her to talk about her view of herself 33. To prevent a valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would A) Assist the client to use the bedside commode B) Administer stool softeners every day as ordered C) Administer anti dysrhythmics prn as ordered D) Maintain the client on strict bed rest The correct answer is B: Administer stool softeners every day as ordered 34. A 3 year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should A) Expose the cast to air and turn the child frequently B) Use a heat lamp to reduce the drying time C) Handle the cast with the abductor bar D) Turn the child as little as possible The correct answer is A: Expose the cast to air and turn the child frequently 35. The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate postoperative period? A) Raise the head of the bed at least 30 degrees B) Encourage ambulation within 24 hours C) Maintain in a flat position, logrolling as needed D) Encourage leg contraction and relaxation after 48 hours The correct answer is C: Maintain in a flat position, logrolling as needed 36. A client was admitted to the psychiatric unit after complaining to her friends andfamily that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to A) Convince the client that the hospital staff is trying to help B) Help the client to enter into group recreational activities C) Provide interactions to help the client learn to trust staff D) Arrange the environment to limit the client’s contact with other clients The correct answer is C: Provide interactions to help the client learn to trust staff 37. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate? A) Unequal leg length B) Limited adduction C) Diminished femoral pulses D) Symmetrical gluteal folds The correct answer is A: Unequal leg length 38. A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to A) A cerebral vascular accident B) Postoperative meningitis C) Medication reaction D) Metabolic alkalosis The correct answer is A: A cerebral vascular accident 39. Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parents remark: “We just don’t know how he caught the disease!” The nurse's response is based on an understanding that A) AGN is a streptococcal infection that involves the kidney tubules B) The disease is easily transmissible in schools and camps C) The illness is usually associated with chronic respiratory infections D) It is not "caught" but is a response to a previous B-hemolytic strep infection The correct answer is D: It is not "caught" but is a response to a previous B-hemolytic strep infection 40. A couple asks the nurse about risks of several birth control methods. What is he most appropriate response by the nurse? A) Norplant is safe and may be removed easily B) Oral contraceptives should not be used by smokers- - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - -- 140. The nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. The first action the nurse would perform is to A) Begin cardiopulmonary resuscitation B) Prepare for immediate defibrillation C) Notify the "Code" team and health care provider D) Assess airway breathing and circulation The correct answer is D: Assess airway breathing and circulation 141. To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment to the A) Finger and toenail quicks B) EyesC) Perianal area D) External ear canals The correct answer is B: Eyes 142. The nurse is caring for a child with cystic fibrosis. The nurse would anticipate that the child would be deficient in which vitamins? A) B, D, and K B) A, D, and K C) A, C, and D D) A, B, and C The correct answer is B: A, D, and K 143. The nurse is teaching a 27 year-old client with asthma about management of their therapeutic regime. Which statement would indicate the need for additional instruction? A) "I should monitor my peak flow every day." B) "I should contact the clinic if I am using my medication more often." C) "I need to limit my exercise, especially activities such as walking and running." D) "I should learn stress reduction and relaxation techniques." The correct answer is C: "I need to limit my exercise, especially activities such as walking and running." 144. While caring for a child with Reye's Syndrome, the nurse should give which action the highest priority? A) Monitor intake and output B) Provide good skin care C) Assess level of consciousness D) Assist with range of motion The correct answer is C: Assess level of consciousness 145. A newborn presents with a pronounced cephalic hematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care? A) Pain related to periosteal injury B) Impaired mobility related to bleeding C) Parental anxiety related to knowledge deficit D) Injury related to inter cranial hemorrhage The correct answer is C: Parental anxiety related to knowledge deficit146. A confused client has been placed in physical restraints by order of the health care provider. Which task could be assigned to an unlicensed assistive personnel (UAP)? A) Assist the client with activities of daily living B) Monitor the clients physical safety C) Evaluate for basic comfort needs D) Document mental status and muscle strength The correct answer is A: Assist with activities of daily living 147. A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the client A) "Be sure and eat a fat-free diet until the test." B) "Do not eat or drink anything but water for 12 hours before the blood test." C) "Have the blood drawn within 2 hours of eating breakfast." D) "Stay at the laboratory so 2 blood samples can be drawn an hour apart." The correct answer is B: "Do not eat or drink anything but water for 12 hours before the blood test." 148. A client who is terminally ill has been receiving high doses of an opiod analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli,what orders would the nurse expect from the health care provider? A) Decrease the analgesic dosage by half B) Discontinue the analgesic C) Continue the same analgesic dosage D) Prescribe a less potent drug The correct answer is C: Continue the same analgesic dosage 149. Which of these clients would the triage nurse request for the health care provider to examine immediately? A) A 5 month-old infant who has audible wheezing and grunting B) An adolescent who has soot over the face and shirt C) A middle-aged man with second degree burns over the right hand D) A toddler with singed ends of long hair that extends to the waist The correct answer is A: A 5 month-old infant who has audible wheezing and grunting 150. An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for trachea esophageal fistula. The mother asks:”When can the tube can be used for feeding?” The nurse's best response would be which of these comments? A) Feedings can begin in 5 to 7 days.B) The use of the feeding tube can begin immediately. C) The stomach contents and air must be drained first. D) The incision healing must be complete before feeding. The correct answer is C: Stomach contents and air must be drained first 151. A pre-term baby develops nasal flaring, cyanosis and diminished breath sounds on one side. The provider's diagnosis is spontaneous pneumothorax. Which procedure should the nurse prepare for first? A) Cardiopulmonary resuscitation B) Insertion of a chest tube C) Oxygen therapy D) Assisted ventilation The correct answer is B: Insertion of a chest tube 152. The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed? A) Extreme fatigue B) Increased appetite C) Intense itching D) Constipation The correct answer is A: Extreme fatigue 153. The nurse is teaching a client with atrial fibrillation about the use of Coumadin (warfarin) at home. Which of these should be emphasized to the client to avoid? A) Large indoor gatherings B) Exposure to sunlight C) Active physical exercise D) Foods rich in vitamin K The correct answer is D: Foods rich in vitamin K 154. A nurse caring for premature newborns in an intensive care setting carefully monitors oxygen concentration. What is the most common complication of this therapy? A) Intraventricular hemorrhage B) Retinopathy of prematurity C) Bronchial pulmonary dysplasia D) Necrotizing enterocolitis The correct answer is B: Retinopathy of prematurity155. A nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse’s contribution and begins to find objections to the suggestion. The nurse manager's best response is to A) Let’s move on to a new action that deals with the problem. B) I think you need to reserve judgment until after all suggestions are offered. C) Very well thought out. Your analytic skills and interest are incredible. D) Let’s move to the ‘what if…’ as related to these objections for an exploration of spin off ideas. The correct answer is D: Let’s move to the ‘what if…’ as related to these objections for an exploration of spin off ideas. 156. The nurse is caring for an acutely ill 10 year-old client. Which of the following assessments would require the nurses immediate attention? A) Rapid bounding pulse B) Temperature of 38.5 degrees Celsius C) Profuse Diaphoresis D) Slow, irregular respirations The correct answer is D: Slow, irregular respirations 157. A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure? A) Playing with toys in a back yard flower garden B) Eating small amounts of grass while playing "farm" C) Playing with cars on the pavement near burning leaves D) Throwing a ball to a neighborhood child who has poison ivy The correct answer is C: Playing with cars on the pavement near burning leaves 158. The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first? A) Weight reduction B) Stress management C) Physical exercise D) Smoking cessation The correct answer is D: Smoking cessation159. The nurse is caring for a 5 year-old child who has the left leg in skeletal traction. Which of the following activities would be an appropriate diversional activity? A) Kicking balloons with right leg B) Playing "Simon Says" C) Playing hand held games D) Throw bean bags The correct answer is C: Playing hand held games 160. The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect? A) Expiratory wheezes B) Blurred vision C) Acites D) Dilated pupils The correct answer is C: Acites [Show More]

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