HESI PN COMPREHENSIVE EXIT EXAM

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HESI PN COMPREHENSIVE EXIT EXAM

VERSION 3

• A nurse is performing tracheostomy care for a client who is postop following a

laryngectomy. Which of the following actions take when suctioning the client’s airway?

• Apply suction for 10 seconds
• A nurse is preparing to administer a long acting insulin to a client who has DM.

Which of the following actions should the nurse take first?

• Check the correct dose with another licensed nurse
• A nurse is caring for an older adult client in the PACU following gen

anesthesia. Which of the following should the nurse report to the provider?

• Audible stridor
• A nurse is planning an educational session for staff nurses about working with

parents whose terminally ill children are candidates for donating their organs.Which of the following information should the nurse plan to include?

• The family can have the child in an open casket without fearing that the

organ donation might disfigure the child’s body.

• Math 0.6mL
• A nurse manager is planning to make changes to the current scheduling system

on the unit. To facilitate the staff’s acceptance of this change, which of the following actions should the nurse manager take first?

• Provide information about scheduling issues to the staff
• A nurse is assessing a client who is receiving a blood transfusion. Which of the

following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction?

• Low back pain
• A nurse is assessing a client who has macular degeneration. Which of the

following findings should the nurse expect?

• Decreased central vision
• A nurse who is working in a long-term care facility is assessing an adult client.

Which of the following findings places the client at risk for development of a pressure injury? 1 / 3

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• Recent weight loss
• A nurse is teaching about TPN and IV lipid emulsion with a client who has

an extensive burn injury. Which of the following information should the nurse include?

• “you will receive finger sticks for blood glucose testing.”
• A nurse is caring for a client who has dehydration secondary to nausea

and vomiting. The nurse should identify which of the following findings as an indication of fluid volume deficit?

• Orthostatic hypotension
• A nurse is caring for a client who is in labor at 39 weeks of gestation. During

the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take?

• Continue observing the fetal heart rate
• A nurse is caring for a client who requires physical therapy

following discharge. Which of the following actions should the nurse take?

• Involve the client in the selection of a physical therapy provider
• A nurse is assessing a client who has sickle cell anemia. The nurse should

identify which of the following findings as a manifestation of vaso-occlusive crisis?

• Hematuria
• A nurse is teaching a group of guardians about child safety measures.

Which of the following statements by a guardian indicates an understanding of the teaching?

• I should have my child avoid sun exposure between 10am and 2pm
• A nurse is caring for four clients at the beginning of a shift. After receiving

change of shift report, which of the following clients should the nurse attend to first?

• A client who is confused and has been attempting to get out of bed.
• A nurse is assessing a client who has been taking lithium carbonate for the

past month to treat bipolar disorder. Which of the following assessment findings should the nurse identify as the priority?

• Confusion 2 / 3

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• A nurse manager is on a planning committee to develop an emergency

preparedness plan. The nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan?

• Notify the incident commander
• A nurse is planning care for a client who is receiving hemodialysis via an

established AV fistula in the right arm. Which of the following interventions should the nurse include in the client’s plan of care?

• Auscultate the affected extremity for a bruit
• A nurse receives a request from a client to review the information in his

medical record. Which of the following responses should the nurse give?

• There is a protocol for reviewing your medical record, and I can initiate

the process

• A nurse is assessing a client who has OSA. For which of the

following complications should the nurse monitor?

• Hypertension
• Math heparin 0.5
• A nurse in an ED is assessing a client who reports taking MDMA. Which

of the following should the nurse expect?

• Diaphoresis
• A nurse is caring for a client who has a terminal illness and requests

no lifesaving measure if a cardiac arrests occurs. Which of the following statements should the nurse make?

• I will provide you with information about medical treatment to include in

your living will

• A nurse is administering cyclophosphamide orally to a school-aged child

who has neuroblastoma. Which of the following actions should nurse take when administering this medication?

• Maintain hydration with liberal fluid intake
• A nurse is reviewing the UA report of a client who has

glomerulonephritis. Which of the following findings should the nurse expect?

• Protein
• A nurse is providing colostomy care for a client using a two piece
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