1. The nurse is caring for a pre-adolescent client in skeletal

2021 HESI EXIT

• The nurse is caring for a pre-adolescent client in skeletal

Dunlop traction. Which nursing intervention is appropriate for this child?

• Make certain the child is maintained in correct body alignment.
• Be sure the traction weights touch the end of the bed.
• Adjust the head and foot of the bed for the child's comfort
• 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.

• 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?

• Height and weight percentiles vary widely
• Growth pattern appears to have slowed
• Recumbent and standing height are different
• Short term weight changes are uneven

The correct answer is A: Height and weight percentiles vary

widely

• 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?

• Teach the parents how to perform cardiopulmonary

resuscitation

• Recommend that the parents give in when he holds his breath

to prevent anoxia

• Advise the parents to ignore breath holding because breathing

will begin as a reflex

• 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

• The nurse is assessing a client in the emergency room. Which

statement suggests that the problem is acute angina?

• "My pain is deep in my chest behind my sternum."
• "When I sit up the pain gets worse."
• "As I take a deep breath the pain gets worse."
• "The pain is right here in my stomach area."

The correct answer is A: "My pain is deep in my chest behind my

sternum." .

• 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? 1 / 4

• "Name the year." "What season is this?" (pause for answer

after each question)

• "Subtract 7 from 100 and then subtract 7 from that." (pause

for answer) "Now continue to subtract 7 from the new number."

• "I am going to say the names of three things and I want you to

repeat them after me:

blue, ball, pen."

• "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."

• In planning care for a 6 month-old infant, what must the nurse

provide to assist in the development of trust?

• Food
• Warmth
• Security
• Comfort

The correct answer is C: Security

• A nurse has just received a medication order which is not

legible. Which statement best reflects assertive communication?

• "I cannot give this medication as it is written. I have no idea of

what you mean."

• "Would you please clarify what you have written so I am sure I

am reading it correctly?"

• "I am having difficulty reading your handwriting. It would save

me time if you would be more careful."

• "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?"

• What is the most important consideration when teaching

parents how to reduce risks in the home?

• Age and knowledge level of the parents
• Proximity to emergency services
• Number of children in the home
• Age of children in the home 2 / 4

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

• Administer a placebo
• Encourage increased fluid intake
• Administer the prescribed analgesia
• Recommend relaxation exercises for pain control

The correct answer is C: Administer the prescribed analgesia

• While caring for a toddler with croup, which initial sign of

croup requires the nurse's immediate attention?

• Respiratory rate of 42
• Lethargy for the past hour
• Apical pulse of 54
• Coughing up copious secretions

The correct answer is A: Respiratory rate of 30

• 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?

• Lethargy
• Heat intolerance
• Diarrhea
• Skin eruptions

The correct answer is A: Lethargy

• 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?

• "Do not worry. Epilepsy can be treated with medications."
• "The seizure may or may not mean your child has epilepsy."
• "Since this was the first convulsion, it may not happen again."
• "Long term treatment will prevent future seizures."

The correct answer is B: "The seizure may or may not mean your

child has epilepsy."

• Alcohol and drug abuse impairs judgment and increases risk

taking behavior. What nursing diagnosis best applies?

• Risk for injury
• Risk for knowledge deficitC) Altered thought process
• Disturbance in self-esteem

The correct answer is A: Risk for injury

• The nurse is caring for a 10 month-old infant who is has

oxygen via mask. It is 3 / 4

important for the nurse to maintain patency of which of these areas?

• Mouth
• Nasal passages
• Back of throat
• Bronchials

The correct answer is B: Nasal passages

• The nurse is providing instructions for a client with

pneumonia. What is the most important information to convey to the client?

• "Take at least 2 weeks off from work."
• "You will need another chest x-ray in 6 weeks."
• "Take your temperature every day."
• "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."

• When counseling a 6 year old who is experiencing enuresis,

what must the nurse understand about the pathophysiological basis of this disorder?

• Has no clear etiology
• May be associated with sleep phobia
• Has a definite genetic link
• Is a sign of willful misbehavior

The correct answer is A: Has no clear etiology

• 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?

• Reprimand the child and give a 15 minute "time out"
• Maintain a permissive attitude for this behavior
• Use patience and a sense of humor to deal with this behavior
• 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

• 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?

• Chewable aspirin is the preferred analgesicB) Topical cortisone

ointment relieves itching

• Papules, vesicles, and crusts will be present at one time
• The illness is only contagious prior to lesion eruption

The correct answer is C: Papules, vesicles, and crusts will be

present at one time

• The nurse is assigned to a client who has heart failure .

During the morning rounds

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