ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)
271. A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at
bedtime. What action should the nurse take?
(correct Answer- Administer the medication as prescribed with a glass of water
A client Who is confused and frequently forgets to go to the bathroom
272. Which client should the nurse assess frequently because of the risk for
273. While monitoring a client during a seizure, which interventions should the
nurse implement? (Select all that apply)
(Correct Answer-
Move obstacles away from the client
Monitor physical movements
Observe for a patent airway
Record the duration of the seizure
274. A male client with a long history of alcoholism is admitted because of mild
confusion and fine motor tremors. He reports that he quit drinking alcohol and
stopped smoking cigarettes one month ago after his brother died of lung cancer.
Which intervention is most important for the nurses to include in the client’s plan
of care?
(correct Answer- Observe for changes in the level of consciousness.
275. An older adult female admitted to the intensive care unit (ICU) with a
possible stroke is intubated with a ventilator setting of tidal volume 600, PlO2 40%,
and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results
after intubation is PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To
normalize the client’s ABG finding, which action is required?
correct Answer- Increase ventilator rate.
276. The mother of the 12- month-old with cystic fibrosis reports that her child is
experiencing increasing congestion despite the use of chest physical therapy (CPT)
twice a day, and has also experienced a loss of appetite. What instruction should
the nurse provide?
(correct Answer- CPT should be performed more frequently, but at least an hour
before meals.
277. The nurse is evaluating the diet teaching of a client with hypertension.
What
dinner selection indicates that the client understands the dietary
recommendation
lime pie
for hypertension?
(correct Answer- Baked pork chop, applesauce, corn on the cob, 2% milk, and key-
278. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic
episodes and glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units
subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h
are prescribed. What action should the nurse include in this client’s plan of care?
(correct Answer- Fingerstick glucose assessment q6h with meals
Review with the client proper foot care and prevention of injury
Coordinate carbohydrate-controlled meals at consistent times and intervals
Teach subcutaneous injection technique, site rotation, and insulin management
279. Which problem reported by a client taking lovastatin requires the most
immediate follow-up by the nurse?
(correct Answer- Provide supplemental oxygen
(correct Answer- Muscle pain
280. While assessing a client’s chest tube (CT), the nurse discovers bubbling in the
water seal chamber of the chest tube collection device. The client’s vital signs are:
blood pressure of 80/40 mmHg, heart rate 120 beats/minute, respiratory rate 32
breaths/minutes, oxygen saturation 88%. Which interventions should the nurse
implement?
Auscultate bilateral lung fields
Reinforce occlusive CT dressing
281. Before leaving the room of a confused client, the nurse notes that a half-bow
the knot was used to attach the client’s wrist restraints to the movable portion of the
client’s bed frame. What action should the nurse take before leaving the room?
(correct Answer- Ensure that the knot can be quickly released.
282. Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis
media. Antipyrine and benzocaine-otic are also prescribed for pain and
inflammation. What instruction should the nurse emphasize concerning the
installation of the antipyrine/benzocaine otic solution?
(correct Answer- Have the child lie with the ear up for one to two minutes after
installation.
283. An older adult male is admitted with complications related to chronic
obstructive pulmonary disease (COPD). He reports progressive dyspnea that
worsens on exertion and his weakness has increased over the past month. The
nurse notes that he has dependent edema in both lower legs. Based on these
assessment findings, which dietary instruction should the nurse provide?
(correct Answer- Restrict daily fluid intake.
(correct Answer- Leave the catheter in place and obtain a sterile catheter.
284. The nurse inserts an indwelling urinary catheter as seen in the video what
action should the nurse take next?
(correct Answer- Prepare the skin for the procedure.
285. A client with coronary artery disease who is experiencing syncopal episodes
is admitted for an electrophysiology study (EPS) and possible cardiac ablation
therapy. Which intervention should the nurse delegate to the unlicensed assistive
personnel (UAP)?
286. Following an outbreak of measles involving 5 students in an elementary
school, which action is most important for the school nurse to take? (correct
Answer- Restrict unvaccinated children from attending school until the measles
outbreak is resolved.
287. A preeclamptic client who delivered 24h ago remains in the labor and
delivery recovery room. She continues to receive magnesium sulfate at 2 grams per
hour. Her total input is limited to 125 ml per hour, and her urinary output for the
last hour was 850 ml. What intervention should the nurse implement?
(correct Answer- Continue with the plan of care for this client
(correct Answer- Begin to show signs of improvement in effect
(correct Answer- Check for a destined bladder
(correct Answer- Encourage popsicles and fluids of choice
288. The nurse is planning care for a client who admits to having suicidal thoughts.
Which client behavior indicates the highest risk for the client acting on these
suicidal thoughts?
289. When assessing a multigravida on the first postpartum day, the nurse finds a
moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths
above the umbilicus. What action should the nurse implement first?
