Texas A&M University, Corpus Christi

NURS 4470

2019 HESI EXIT V1

1)After an explosion at a factory one of the workers approaches the nurse and says “I

am an unlicensed assistive personnel (UAP) at the local hospital.” Which of these tasks

should the nurse assign to this worker who wants to help during the care of the wounded

workers?

1. Get temperatures
2. Take blood pressure
3. Palpate pulses
4. Check alertness

2. Which of these clients would the nurse recommend to keep in the hospital during an

internal disaster at the agency?

1. An adolescent diagnosed with sepsis 7 days ago with vital signs maintained within

low normal

2. A middle-aged woman documented to have had an uncomplicated myocardial

infarction 4 days ago

3. An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis
4. A young adult in the second day of treatment for an overdose of acetometaphen

3. The mother of a toddler who is being treated for pesticide poisoning asks: “Why is

activated charcoal used? What does it do?” What is the nurse's best response?

1. ”Activated charcoal decreases the systemic absorption of the poison from the

stomach."

2. ”The charcoal absorbs the poison and forms a compound that doesn't hurt your child."
3. ”This substance helps to get the poison out of the body by the gastrointestinal system."
4. ”The action may bind or inactivate the toxins or irritants that are ingested by children

or adults."

4. The nurse is to administer a new medication to a client. Which actions are in the best

interest of the client? Verify the order for the medication. Prior to giving the medication

the nurse should say

1. ”Please state your name?" Upon entering the room the nurse should ask:
2. ”What is your name? What allergies do you have?" then check the client's name band

and allergy band As the room is entered say

3. "What is your name?" then check the client's name band Verify the client's allergies

on the admission sheet and order.

4. “Verify the client's name on the name plate outside the room then as the nurse enters

the room ask the client "What is your first, middle and last name?

5. Several clients are admitted to an adult medical unit. The nurse would ensure

airborne precautions for a client with which medical condition?

1. Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV)
2. A positive purified protein derivative with an abnormal chest x-ray
3. A tentative diagnosis of viral pneumonia with productive brown sputum
4. Advanced carcinoma of the lung with hemoptasis

6. A client is scheduled to receive an oral solution of radioactive iodine (131I). In order

to reduce hazards, the priority information for the nurse to include during the instructions

to the client is which of these statements?

1. In the initial 48 hours avoid contact with children and pregnant women, and after

urination or defecation flush the commode twice.

2. Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose,

do so in the toilet and flush it twice.

3. Your family can use the same bathroom that you use without any special precautions.
4. Drink plenty of water and empty your bladder often during the initial 3 days of

therapy.

7. Which approach is the best way to prevent infections when providing care to clients

in the home setting?

1. Hand washing before and after examination of clients
2. Wearing non powdered latex free gloves to examine the client
3. Using a barrier between the client's furniture and the nurse's bag
4. Wearing a mask with a shield during any eye/mouth/nose examination

8. A 10 year-old child has a history of epilepsy with tonic-clonic seizures. The school

nurse should instruct the classroom teacher that if the child experiences a seizure in the

classroom, the most important action during the seizure would be to

1. Move any chairs or desks at least 3 feet away from the child
2. Note the sequence of movements with the time lapse of the event
3. Provide privacy as much as possible to minimize fighting the other children
4. Place the hands or a folded blanket under the head of the child

9. A mother calls the hospital hot line and is connected to the triage nurse. The mother

proclaims: “I found my child with odd stuff coming from the mouth and an unmarked

bottle nearby.” Which of these

comments would be the best for the nurse to ask the mother to determine if the child has

swallowed a corrosive substance?

1. Ask the child if the mouth is burning or throat pain is present
2. Take the child’s pulse at the wrist and see if the child is has trouble breathing lying

flat.

3. What color is the child’s lips and nails and has the child voided today?
4. Has the child had vomiting or diarrhea or stomach cramps yet?

10. The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of

these protocols would be a priority for the nurse to implement?

1. Have the client cough into a tissue and dispose in a separate bag
2. Instruct the client to cover the mouth with a tissue when coughing
3. Reinforce for all to wash their hands before and after entering the room
4. Place client in a negative pressure private room and have all who enter the room use

masks with shields

who enter the room use masks with shields

11. The charge nurse is planning assignments on a medical unit. Which client should be

assigned to the PN?

1. Test a stool specimen for occult blood
2. Assist with the ambulation of a client with a chest tube
3. Irrigate and redress a leg wound
4. Admit a client from the emergency room

12. When assessing a client, it is important for the nurse to be informed about cultural

issues related to the client's background because

1. Normal patterns of behavior may be labeled as deviant, immoral, or insane
2. The meaning of the client's behavior can be derived from conventional wisdom
3. Personal values will guide the interaction between persons from 2 cultures
4. The nurse should rely on her knowledge of different developmental mental stages

13. The nurse is responsible for several elderly clients, including a client on bed rest

with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment

for this client?

1. Assign an RN to provide total care of the client
2. Assign a nursing assistant to help the client with self-care activities
3. Delegate complete care to an unlicensed assistive personnel
4. Supervise a nursing assistant for skin care

14. The nursing student is discussing with a preceptor the delegation of tasks to an

unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the

student needs further teaching about the delegation process?

1. Assist a client post cerebral vascular accident to ambulate
2. Feed a 2 year-old in balanced skeletal traction
3. Care for a client with discharge orders
4. Collect a sputum specimen for acid fast bacillus

15. After working with a very demanding client, an unlicensed assistive personnel

(UAP) tells the nurse, "I have had it with that client. I just can’t do anything that pleases

him. I’m not going in there again." The nurse should respond by saying

1. ”He has a lot of problems. You need to have patience with him."
2. ”I will talk with him and try to figure out what to do."
3. ”He is scared and taking it out on you. Let's talk to figure out what to do."
4. ”Ignore him and get the rest of your work done. Someone else can take care of him for

the rest of the day."

16. A client with a diagnosis of bipolar disorder has been referred to a local boarding

home for consideration for placement. The social worker telephoned the hospital unit for

information about the client’s mental status and adjustment. The appropriate response of

the nurse should be which of these statements?

1. I am sorry. Referral information can only be provided by the client’s health care

providers.

2. “I can never give any information out by telephone. How do I know who you are?"
3. Since this is a referral, I can give you the this information.
4. I need to get the client’s written consent before I release any information to you.

17. A client is admitted with a diagnosis of schizophrenia. The client refuses to take

medication and states “I don’t think I need those medications. They make me too sleepy

and drowsy. I insist that you explain their use and side effects.” The nurse should

understand that

1. A referral is needed to the psychiatrist who is to provide the client with answers
2. The client has a right to know about the prescribed medications
3. Such education is an independent decision of the individual nurse whether or not to

teach clients about their medications

4. Clients with schizophrenia are at a higher risk of psychosocial complications when

they know about their medication side effects

18. Which statement by the nurse is appropriate when asking an unlicensed assistive

personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?

1. ”Have the client sit on the side of the bed for at least 2 minutes before helping him

stand."

2. ”If the client is dizzy on standing, ask him to take some deep breaths."
3. ”Assist the client to the bathroom at least twice on this shift."
4. ”After you assist him to the chair, let me know how he feels."

19. The nurse receives a report on an older adult client with middle stage dementia.

What information suggests the nurse should do immediate follow up rather than delegate

care to the nursing assistant? The client

1. Has had a change in respiratory rate by an increase of 2 breaths
2. Has had a change in heart rate by an increase of 10 beats
3. Was minimally responsive to voice and touch
4. Has had a blood pressure change by a drop in 8 mmHg systolic

20. A client tells the nurse, "I have something very important to tell you if you promise

not to tell." The best response by the nurse is

1. ”I must document and report any information."
2. ”I can’t make such a promise."
3. ”That depends on what you tell me."
4. ”I must report everything to the treatment team.

21. Which task could be safely delegated by the nurse to an unlicensed assistive

personnel (UAP)?

1. Be with a client who self-administers insulin
2. Cleanse and dress a small decubitus ulcer
3. Monitor a client's response to passive range of motion exercises
4. Apply and care for a client's rectal pouch

22. A client asks the nurse to call the police and states: “I need to report that I am being

abused by a nurse.” The nurse should first

1. Focus on reality orientation to place and person
2. Assist with the report of the client’s complaint to the police
3. Obtain more details of the client’s claim of abuse
4. Document the statement on the client’s chart with a report to the manager

23. A nurse from the maternity unit is floated to the critical care unit because of staff

shortage on the evening shift. Which client would be appropriate to assign to this nurse?

A client with

1. A Dopamine drip IV with vital signs monitored every 5 minutes
2. A myocardial infarction that is free from pain and dysrhythmias
3. A tracheotomy of 24 hours in some respiratory distress
4. A pacemaker inserted this morning with intermittent capture

24. An unlicensed assistive personnel (UAP), who usually works on a surgical unit is

assigned to float to a pediatric unit. Which question by the charge nurse would be most

appropriate when making delegation decisions?

1. ”How long have you been a UAP and what units you have worked on?"
2. ”What type of care do you give on the surgical unit and what ages of clients?"
3. “What is your comfort level in caring for children and at what ages?"
4. ”Have you reviewed the list of expected skills you might need on this unit?"

25. A client frequently admitted to the locked psychiatric unit repeatedly compliments

and invites one of the nurses to go out on a date. The nurse’s response should be to

1. Ask to not be assigned to this client or to work on another unit
2. Tell the client that such behavior is inappropriate
3. Inform the client that hospital policy prohibits staff to date clients
4. Discuss the boundaries of the therapeutic relationship with the client

26. A client has a nasogastric tube after colon surgery. Which one of these tasks can be

safely delegated to an unlicensed assistive personnel (UAP)?

1. To observe the type and amount of nasogastric tube drainage
2. Monitor the client for nausea or other complications
3. Irrigate the nasogastric tube with the ordered irrigate
4. Perform nostril and mouth care

27. The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia.

Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)?

1. Test blood sugar every 2 hours by accu check
2. Review with family and client signs of hyperglycemia
3. Monitor for mental status changes
4. Check skin condition of lower extremities

28. A nurse is working with one licensed practical nurse (PN), a student nurse and an

unlicensed assistive personnel (UAP). Which newly admitted clients would be most

appropriate to assign to the UAP?

1. A 76-year-old client with severe depression
2. A middle-aged client with an obsessive compulsive disorder
3. A adolescent with dehydration and anorexia
4. A young adult who is a heroin addict in withdrawal with hallucinations

29. The unlicensed assistive personnel (UAP) reports a sudden increase in temperature

to 101 degrees F for a post surgical client. The nurse checks on the client’s condition and

observes a cup of steaming coffee at the bedside. What instructions are appropriate to

give to the UAP?

1. Encourage oral fluids for the temperature elevation
2. Check temperature 15 minutes after hot liquids are taken
3. Ask the client to drink only cold water and juices
4. Chart this temperature elevation on the flow sheet

30. A client continuously calls out to the nursing staff when anyone passes the client’s

door and asks them to do something in the room. The best response by the charge nurse

would be to

1. Keep the client’s room door cracked to minimize the distractions
2. Assign 1 of the nursing staff to visit the client regularly
3. Reassure the client that 1 staff person will check frequently if the client needs

anything

4. Arrange for each staff member to go into the client’s room to check on needs every

hour on the hour

31. A client with a new diagnosis of diabetes mellitus is referred for home care. A family

member present expresses concern that the client seems depressed. The nurse should

initially focus assessment by using which approach?

1. The results of a standardized tool that measures depression
2. Observation of affect and behavior
3. Inquiry about use of alcohol
4. Family history of emotional problems or mental illness

32. A mother with a Roman Catholic belief has given birth in an ambulance on the way

to the hospital. The neonate is in very critical condition with little expectation of

surviving the trip to the hospital. Which of these requests should the nurse in the

ambulance anticipate and be prepared to do?

1. The refusal of any treatment for self and the neonate until she talks to a reader
2. The placement of a rosary necklace around the neonate's neck and not to remove it

unless absolutely necessary

3. Arrange for a church elder to be at the emergency department when the ambulance

arrives so a "laying on hands" can be done

4. Pour fluid over the forehead backwards towards the back of the head and say "I

baptize you in the name of the father, the son and the holy spirit. Amen.

33. An American Indian chief visits his newborn son and performs a traditional

ceremony that involves feathers and chanting. The attending nurse tells a colleague "I

wonder if he has any idea how

ridiculous he looks -- he's a grown man!" The nurse's response is an example of

1. Discrimination
2. Stereotyping
3. Ethnocentrism
4. Prejudice

34. A client expresses anger when the call light is not answered within 5 minutes. The

client demanded a blanket. The best response for the nurse to make is

1. "I apologize for the delay. I was involved in an emergency."
2. "Let's talk. Why are you upset about this?"

3. "I am surprised that you are upset. The request could have waited a few more

minutes."

4. "I see this is frustrating for you. I have a few minutes so let's talk.

35. An elderly client who lives in a retirement community is admitted with these

behaviors as reported by the daughter: absence in the daily senior group activity, missing

the weekly card games, a change in

calling the daughter from daily to once a week, and the client's tomato garden is

overgrown with weeds. The nurse should assign this client to a room with which one of

these clients?

1. An adolescent who was admitted the day before with acute situational depression
2. A middle aged person who has been on the unit for 72 hours with a dysthymia
3. An elderly person who was admitted 3 hours ago with cycothymia
4. A young adult who was admitted 24 hours ago for detoxification

36. A client diagnosed with anorexia nervosa states after lunch, "I shouldn’t have eaten

all of that sandwich, I don’t know why I ate it, I wasn’t hungry." The client’s comments

indicate that the client is likely experiencing

1. Guilt
2. Bloating
3. Anxiety
4. Fear

37. A 65-year-old Catholic Hispanic-Latino client with prostate cancer adamantly

refuses pain medication because the client believes that suffering is part of life. The client

states “everyone’s life is in God's hands.” The next action for the nurse to take is to

1. Report the situation to the health care provider
2. Discuss the situation with the client's family

3. Ask the client if talking with a priest would be desired
4. Document the situation on the notes

38. A teenage female is admitted with the diagnosis of anorexia nervosa.

Upon

admission, the nurse finds a bottle of assorted pills in the client’s drawer.

The client tells

the nurse that they are antacids for stomach pains. The best response by the nurse would

be

1. "These pills aren’t antacids since they are all different."
2. "Some teenagers use pills to lose weight."
3. "Tell me about your week prior to being admitted."
4. "Are you taking pills to change your weight?"

39. A client who has a belief based in Hinduism is nearing death. The nurse should plan

for which action?

1. After death a Hindu priest will pour water into the mouth of the client and tie a thread

around the client's wrist

2. The elders may be with the client during the process of the client dying and no last

rites are given

3. The family must be with the client during the process of dying and be the only ones to

wash the body after death

4. The body is ritually cleansed and burial is to be as soon as possible after the death

Occurs

40. An explosion has occurred at a high school for children with special needs and

severe developmental delays. One of the students accompanied with a parent is seen at a

community health center a day later. After the initial assessment the nurse concludes that

the student appears to be in a crisis state. Which of these interventions based on crisis

intervention principles is appropriate to do next?

1. Help the student to identify a specific problem
2. Ask the parent to identify the major problem
3. Ask the student to think of different alternatives
4. Examine with the parent a variety of options

41. Which statement made by a client to the admitting nurse suggests that the client is

experiencing a manic episode?

1. "I think all children should have their heads shaved."
2. "I have been restricted in thought and harmed."
3. "I have powers to get you whatever you wish, no matter the cost."
4. "I think all of my contacts last week have attempted to poison me."

42. A client says, "It's raining outside and it's raining in my heart. Did you know that St.

Patrick drove the snakes out of Ireland? I've never been to Ireland." The nurse would

document this behavior as

1. Perseveration
2. Circumstantiality
3. Neologisms
4. Flight of ideas

43. During the change-of-shift report the assigned nurse notes a Catholic client is

scheduled to be admitted for the delivery of a ninth child. Which comment stated angrily

to a colleague by this nurse indicates an attitude of prejudice?

1. "I wonder who is paying for this trip to the hospital?"
2. "I think she needs to go to the city hospital."
3. "All those people indulge in large families!"
4. "Doesn't she know there's such a thing as birth control?"

44. Which of these statements by the nurse reflects the best use of therapeutic

interaction techniques?

1. ”You look upset. Would you like to talk about it?"
2. ”I’d like to know more about your family. Tell me about them."
3. ”I understand that you lost your partner. I don't think I could go on if that happened to

me."

4. ”You look very sad. How long have you been this way?"

45. A nurse in the emergency department suspects domestic violence as the cause of a

client's injuries. What action should the nurse take first?

1. Ask client if there are any old injuries also present
2. Interview the client without the persons who came with the client
3. Gain client's trust by not being hurried during the intake process
4. Photograph the specific injuries in question

46. Which of these findings would indicate that the nurse-client relationship has passed

from the orientation phase to the working phase? The client

1. Has revitalized a relationship with her family to help cope with the death of a daughter
2. Had recognized regressive behavior as a defense mechanism
3. Expresses a desire to be cared for and pampered
4. Recognizes feelings with appropriate expression of feelings

47. A client who is thought to be homeless is brought to the emergency department by

police. The client is unkempt, has difficulty concentrating, is unable to sit still and speaks

in a loud tone of voice.

Which of these actions is the appropriate nursing intervention for the client at this time?

1. Allow the client to randomly move about the holding area until a hospital room is

available

2. Engage the client in an activity that requires focus and individual effort
3. Isolate the client in a secure room until control is regained by the client
4. Locate a room that has minimal stimulation outside of it for admission process

48. A 2 day-old child with spina bifida and meningomyocele is in the intensive care unit

after the initial surgery. As the nurse accompanies the grandparents for a first visit, which

response should the nurse anticipate of the grandparents?

1. Depression
2. Anger
3. Frustration
4. Disbelief

49. Which statement by the client during the initial assessment in the the emergency

department is most indicative for suspected domestic violence?

1. ”I am determined to leave my house in a week."
2. ”No one else in the family has been treated like this."
3. ”I have only been married for 2 months."
4. ”I have tried leaving, but have always gone back."

50. A nurse states: "I dislike caring for African-American clients because they are all so

hostile." The nurse's statement is an example of

1. Prejudice
2. Discrimination
3. Stereotyping
4. Racism

51. Which statement made by a nurse about the goal of total quality management or

continuous quality improvement in a health care setting is correct?

1. “It is to observe reactive service and product problem solving."
2. Improvement of the processes in a proactive, preventive mode is paramount.
3. A chart audits to finds common errors in practice and outcomes associated with goals.
4. A flow chart to organize daily tasks is critical to the initial stages.

52. The nurse manager informs the nursing staff at morning report that the clinical nurse

specialist will be conducting a research study on staff attitudes toward client care. All

staff are invited to participate in the study if they wish. This affirms the ethical principle

of

1. Anonymity
2. Beneficence

3. Justice
4. Autonomy

53. When teaching a client about the side effects of fluoxetine (Prozac), which of the

following will be included?

1. Tachycardia blurred vision, hypotension, anorexia
2. Orthostatic hypotension, vertigo, reactions to tyramine rich foods
3. Diarrhea, dry mouth, weight loss, reduced libido
4. Photosensitivity, seizures, edema, hyperglycemia

54. The nurse is performing an assessment of the motor function in a client with a head

injury. The best technique is

1. A firm touch to the trapezius muscle or arm
2. Pinching any body part
3. Sternal rub
4. Gentle pressure on eye orbit

55. The nurse is teaching about non steroidal anti-inflammatory drugs to a group of

arthritic clients. To minimize the side effects, the nurse should emphasize which of the

following actions?

1. Reporting joint stiffness in the morning
2. Taking the medication 1 hour before or 2 hours after meals
3. Using alcohol in moderation unless driving
4. Continuing to take aspirin for short term relief

56. A client taking isoniazide (INH) for tuberculosis asks the nurse about side effects of

the medication. The client should be instructed to immediately report which of these?

1. Double vision and visual halos
2. Extremity tingling and numbness
3. Confusion and lightheadedness
4. Sensitivity of sunlight

57. The nurse admits a 2 year-old child who has had a seizure. Which of the following

statement by the child's parent would be important in determining the etiology of the

seizure?