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HESI EXIT V4 EXAM
with NGN Questions and Rationalized Answers,
100% VERIFIED NEWEST VERSION.
The exam has: 160 Multiple-choice questions
Performance Score is Above 1100
1. Well making rounds, the charge nurse notices that a young adult client with
asthma who has admitted yesterday is sitting on the side of the bed and
leaning over the side table. The client is currently receiving oxygen at 2 L
per minute via nasal cannula. The client is wheezing and is using purse lips
breathing. Which intervention should the nurse implement?
A) Increase oxygen to 6 L per minute.
B) Call for an Ambu resuscitation bag.
C) This is the client to lie back in bed.
D) Administer a nebulizer treatment
Ans>> D) Administer a nebulizer treatment.
The client with asthma is exhibiting signs of respiratory distress, including wheezing
and using accessory muscles for breathing. Administering a nebulizer treatment with
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a bronchodilator medication such as albuterol is a priority intervention in managing
acute asthma exacerbations. Nebulizer treatments help dilate the airways, relieve
bronchospasm, and improve airflow, which can alleviate respiratory distress and
improve the client's breathing
2. Which Client should the nurse assess frequently because of the risk for
overflow incontinence?
A) a client with hematuria and decreasing hemoglobin and hematocrit levels.
B) A client who has been fast, with increased serum creatinine levels.
C) A client who is confused and frequently forgets to go to the bathroom.
D) A client who has a history of frequent urinary tract infections
Ans>> C) A client who is confused and frequently forgets to go to the bathroom.
Overflow incontinence occurs when the bladder is unable to empty completely,
leading to frequent dribbling or leakage of urine. It often occurs in situations where
there is an obstruction or impairment of bladder emptying.
3. When preparing to administer a prescribed medication to a homeless client
at a community psychiatric clinic. The client tells the nurse that the usual
dosage taken is different from the dose the nurse is giving. Which action
should the nurse take?
A) Inform the client that he may refuse the medication and document whether
or not the client takes it.
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B) Withhold the medication until the dosage can be confirmed.
C) Explain to the client that the dosage has been changed.
D) Tell the client to take the medication then verify the dosage at the next
healthcare team meeting
Ans>> B) Withhold the medication until the dosage can be
confirmed.
4. The charge nurse is making assignments for one practical nurse and three
registered nurses who are caring for neurologically compromised clients.
Which client with which change in status is best to assign to the LPN?
A) Subdural hematoma whose blood pressure changed from 150/80 to 170/60.
B) Viral meningitis whose temperature change from 101 S to 102F.
C) Diabetic keto acidosis who is Glasgow coma scale score changed from 10
to 7.
D) Myxedema, whose blood pressure change from 80/50 to 70/40
Ans>> B) Viral meningitis whose temperature change from 101F to 102F.
(changing temperature requires low risk medication)
5. The nurse is caring for a client with pneumonia who now develops initial
signs of septic shock and multi organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse
to include in the plan of care?
A) Maintain strict intake and output.
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B) Keep head of bed raised 45°.
C) Excess warmth of extremities.
D) Monitor blood glucose level
Ans>> A) Maintain strict intake and output.
(septic shock causes extreme vasodilation which lowers BP resulting in low O2
distribution to the tissue. Need to monitor Fluid levels to keep BP up for adequate
perfusion)
6. And adolescent client is admitted to the hospital because of writing a
suicide note to a teacher at school. On the second day of hospitalization, the
nurse asked the client to meet with the treatment team. After the team meeting,
the client leaves in tears and goes to their room. Which nursing intervention
is best?
A) Let the client rest quietly in their room for a while.
B) Explore the clients goals and desire for treatment.
C) Ask the treatment team about the clients behavior.
D) Go to the clients room and ask what happened
Ans>> D) Go to the clients room and ask what happened.
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(it's important to allow the patient to relay their feelings if she chooses to)
7. The healthcare provider prescribes dalteparin 200 units per kilogram subcutaneous once a day for a client who weighs 154 pounds. The medication is
available and 25,000 units per milliliter vial. How many milliliters should the
nurse administer? (Enter numerical value only. If rounding is required, round
to the nearest 10th.): 0.6
Prescribed: 200units SUBQ 1x/kg/day
Wt: 154lb (70kg)
Dose: 25,000 units/mL
200 x 70 = 14,000 units
14,000/25,000 units = 0.56 --> 0.6
8. NGN: The client is a 49-year-old male who reports flu like symptoms including fever and chest congestion for four days. He came to the emergency
department last night when he was having more difficulty breathing he has a
history of 1/2 pack a day cigarette smoking for 20 years. He has no significant
medical or surgical history.
Which two orders should the nurse complete first?
A) Sputum culture.
B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
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D) Chest x-ray.
E) Acetaminophen 350 mg PO every six hours for temperature control.
F) Run 0.9% sodium chloride IV infusion at 150 mL per hour.
G) Start peripheral IV.
H) NPO
Ans>> B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
(Address the ABC's first)
9. NGN: 0330: place the client on a cardiorespiratory monitor, NPO, sputum
culture, start a peripheral IV infusion, start oxygen 3 L per minute via nasal
cannula, begin 0.9% sodium chloride IV infusion at 150 mL per hour, acetaminophen 350 mg PO every six hours for temperature.
To start the client on oxygen as ordered which items should the nurse collects
from the supply room? SATA
A) humidifier bottle.
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B) Suction canister.
C) Sterile water.
D) Nasal cannula.
E) Flow meter.
F) Lambs wool.
G) Tape
Ans>> A) humidifier bottle.
D) Nasal cannula.
E) Flow meter.
F) Lambs wool.
In order to start a client on 3 L/minute of oxygen via nasal cannula as ordered, the
nurse should collect a flowmeter to adjust the flow of oxygen, lamb's wool to protect
the client's skin, a nasal cannula, and a humidifier bottle with sterile water to prevent
drying as a result of the flow of oxygen.
10. NGN: states, I am feeling extremely anxious right now. The client has
decreased breath sounds in the left lower low. His mucus membranes are dry.
He has a productive cough with thick, yellow secretions. His capillary refill is
four seconds. Vital signs, temperature 100.2. Heart rate 101 bpm, respiratory
rate 28 breaths per minute, blood pressure 145/89, oxygen saturation 90% on
room air.
(for each body system click to specify the assessment findings that indicates
hypoxia)
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Cardiovascular: heart rate 100 bpm, capillary refill for seconds, blood pressure
145/89.
Neurological: anxious, awake and alert, restless.
Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm,
productive cough
Ans>> Cardiovascular: capillary refill for seconds, blood pressure 145/89.
Neurological: anxious, restless.
Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm.
11. NGN: The client is a 49-year-old male who reports flu like symptoms
including fever and chest congestion for four days. He came to the emergency
department last night when he was having more difficulty breathing he has a
history of 1/2 pack a day cigarette smoking for 20 years. He has no significant
medical or surgical history.
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The nurse should place the client in a
position to promote
Ans>> Semi-Fowler , lung expansion.
12. NGN: Orders: 0330: place the client on a cardio respiratory monitor, NPO,
sputum culture, start a PIV, start oxygen 3L via nasal cannula, normal saline
150 ML per hour, acetaminophen 350mg PO every six hours for temp greater
than 101F, chest x-ray.
0500: Oxygen 8Lvia simple facemask, titrate to keep oxygen saturation greater
than 94%.
(mark whether the statements by the new grad nurse indicate understanding
or no understanding of the use of facemask in the care of this client)
-I should clean the facemask once per shift.
-The client should take a 1 to 2 minute break from the facemask each hour.
-I should put gauze under the elastic straps over the ears.
-I can adjust the oxygen level on the flow meter to keep the clients oxygen
saturation greater than 94%.
-The mask should cover only the mouth and leave the nose open for expiration.
-I should place the mask first over the nose and then cover the mouth
Ans>> -I should clean the facemask once per shift. (UNDERSTANDING)
-The client should take a 1 to 2 minute break from the facemask each hour. (NOT
UNDERSTANDING)
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-I should put gauze under the elastic straps over the ears. (NOT UNDERSTANDING
????)
-I can adjust the oxygen level on the flow meter to keep the clients oxygen saturation
greater than 94%. (UNDERSTANDING)
-The mask should cover only the mouth and leave the nose open for expiration. (NOT
UNDERSTANDING)
-I should place the mask first over the nose and then cover the mouth. (UNDERSTANDING)
13. NGN: Nurses Notes: 0400, the client is awake and alert but restless. He
states I am feeling extremely anxious right now. The client has decreased
breath sounds in the left lower lobe. His mucus membranes are dry. He has