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HESI EXIT V5 EXAM
with NGN Questions and Rationalized Answers,
100% VERIFIED NEWEST VERSION.
The exam has: 160 Multiple-choice questions
Performance Score is Above 1100
1. An adult woman who has a history of inferior myocardial infarction,
esophageal reflux, and type 1 diabetes mellitus is admitted to the telemetry
unit for sudden onset of dizziness with palpitations and a burning sensation
in her chest. Which intervention should the nurse implement first?
a. Evaluate telemetry cardiac rhythm
b. Administer an oral antacid
c. Assess blood glucose level
d. Review clients last meal choices
Ans>> a. Evaluate telemetry cardiac rhythm
The client's history of inferior myocardial infarction, along with the sudden onset of
dizziness, palpitations, and a burning sensation in the chest, raises concerns about
a cardiac event or arrhythmia. Therefore, the nurse should immediately assess the
client's cardiac rhythm using telemetry to determine if any life-threatening arrhyth-
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mias or changes in cardiac function are present. This assessment will help guide
further interventions and treatment.
2. When conducting diet teaching for a client who was diagnosed with a
myocardial infarction, which snack foods should the nurse encourage the
client to eat? Select all that apply.
a. Chicken bouillon soup and toast
b. Fresh vegetables with mayonnaise dip
c. Fresh Turkey slices and berries
d. Raw unsalted almonds and apples
e. Soda crackers and peanut butter
Ans>> c. Fresh Turkey slices and berries
d. Raw unsalted almonds and apples
c
Fresh turkey, especially if it's lean and not processed, is a good source of protein
and is generally low in saturated fat. Berries are high in antioxidants and fiber, making
them an excellent choice for a heart-healthy diet.
d
Almonds are a good source of healthy fats, fiber, and protein, and they are
beneficial for heart health when eaten in moderation. Apples are high in fiber and
various health-promoting compounds. Choosing unsalted almonds helps to keep
sodium intake low.
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3. A male client who is experiencing musculoskeletal pain is discharged with
instructions to take ibuprofen, on non-steroidal anti-inflammatory drug by
mouth BID. After receiving discharge teaching, the client states he plans to
take the medication twice daily, with breakfast and dinner. How should the
nurse respond?
a. Review the need to limit intake of leafy, green vegetables such as spinach
b. Confirm that the client has an effective plan for when to take the medication
c. Explain the need to take the medication before meals to increase absorption
d. Remind the client to increase fluid intake while taking the medication
Ans>> b. Confirm that the client has an effective plan for when to take the
medication
The client's statement about planning to take ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), twice daily with breakfast and dinner aligns well with the
prescribed regimen of BID (twice daily) dosing. Taking NSAIDs with meals can help
minimize gastrointestinal side effects such as stomach irritation, which is a common
concern with these medications. Therefore, the nurse should confirm that this is an
effective and appropriate plan.
4. A client at 28 weeks' gestation is admitted to the obstetrical unit following
her involvement in a motor vehicle collision. After stabilizing the client, the
nurse obtains a fetal monitor reading. What action should the nurse take if
fetal tachycardia is assessed on the monitor?
a. Recount the heart rate manually to confirm a monitor malfunction
b. Contact the health care provider after initiating oxygen per face mask
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c. Explain that there is no indication the fetal heart rate is due to trauma
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d. Evaluate the presence of preterm labor by performing a vaginal examination
Ans>> b. Contact the health care provider after initiating oxygen per face mask
Fetal tachycardia (an abnormally high fetal heart rate) can be an indication of
fetal distress or other issues that require medical evaluation. Initiating oxygen via
a face mask is a standard initial intervention to ensure that both the mother and
fetus receive adequate oxygenation. Following this, it is important to contact the
healthcare provider for further assessment and guidance on the next steps in the
client's care.
5. Four hours after the nurse administers interferon alpha subcutaneously into
a client, the client develops a headache, muscle aches and a fever of 101.8
degrees Fahrenheit. What action should the nurse implement?
a. Administer prescribed PRN dose of acetaminophen for these side effects
b. Explain that an antihistamine may be needed in response to this allergic
reaction
c. Document these findings as an idiosyncratic response to this medication
d. Observed the site where the medication was injected for signs of local
reaction
Ans>> a. Administer prescribed PRN dose of acetaminophen for these side
effects
Flu-like symptoms are common side effects of interferon therapy, and
acetaminophen can help alleviate these symptoms. It is essential to provide relief to
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the
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client to improve their comfort and tolerance of the medication.
6. The nurse is caring for a client with a suspected diagnosis of osteomyelitis.
Which diagnostic test should the nurse prepare the client to expect the health
care provider to prescribe?
a. Radiographs
b. Radionuclide bone scan
c. C reactive protein tests
d. Erythrocytes sedimentation rate
Ans>> b. Radionuclide bone scan
A radionuclide bone scan is a diagnostic test commonly used to detect and evaluate
bone infections like osteomyelitis. It can help identify areas of increased bone activity,
which may be indicative of an infection. This test can provide valuable information
to aid in the diagnosis and management of osteomyelitis.
7. When the nurse attempts to teach self-administration of insulin injections
to a client who is newly diagnosed with type one diabetes mellitus, the client
tells the nurse in a loud voice to leave the room. What action should the nurse
take?
a. Leave the clients room and return later in the day
b. Explain that insulin is a life saving drug for the client
c. Encourage client to implement relaxation techniques
d. Refer the client to the social worker for support therapy
Ans>> a. Leave the clients room and return later in the day
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This response respects the client's immediate wish for space while acknowledging
the importance of the teaching that needs to occur. The client's reaction may be due
to a variety of factors such as fear, overwhelm, or denial regarding the new diagnosis.
Giving the client some time to process their emotions can be beneficial. The nurse
can return later when the client may be more receptive to learning.
8. What is the primary goal when planning nursing care for a client with
degenerative joint disease?
a. Improve stress management skills
b. Achieve satisfactory pain control
c. Obtain adequate rest and sleep
d. Reduce risk for infection
Ans>> b. Achieve satisfactory pain control
Pain control is a central aspect of care for individuals with degenerative joint disease
because pain is one of the most common and debilitating symptoms associated
with this condition. Effective pain management can improve the client's quality of
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life, increase mobility, and enhance overall functioning. It is crucial to address pain
as a priority when caring for clients with degenerative joint disease to promote their
comfort and well-being.
9. The nurse observes an unlicensed assistive personnel (UAP) who is preparing to provide personal care for a client who requires contact precautions.The
UAP has applied a gown and gloves and secured the tops of the gloves over
the gown sleeves. What action should the nurse take?
a. Remind the UAP to wash hands frequently while in the room
b. Help the UAP reposition the gown sleeve over the glove edges
c. Confirm that the gown is tied securely at the neck and waist
d. Assist the UAP with application of a face mask or face shield
Ans>> c. confirm that the gown is tied securely at the neck and waist
10. While the nurse is conducting an admission assessment of a female client
with bipolar disorder, the client suddenly begins to take off her clothes and
throw them about the room. Which action should the nurse take first?
a. State it is unacceptable to undress during interview
b. Change to less anxiety promoting questions
c. Leave the client's room so she can act out her anxiety
d. Ignore the client's inappropriate behavior
Ans>> a. State it is unacceptable to un- dress during interview
Setting clear and firm boundaries in a respectful and non-confrontational manner is
crucial. The nurse should calmly but firmly inform the client that undressing during
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the interview is not acceptable behavior. This approach respects the client's dignity
while maintaining a safe and appropriate environment.
11. The nurse is planning care for a client who has a fourth-degree midline
laceration that occurred during vaginal delivery of an 8 pound 10 ounce infant.
Which intervention has the highest priority for this client?
a. Administer prescribed PRN sleep medications
b. Administer prescribed stool softener
c. Encourage use of prescribed analgesic perennial sprays
d. Encourage breastfeeding to promote uterine involution
Ans>> b. Administer pre- scribed stool softener
A fourth-degree midline laceration is a severe perineal laceration that extends
through the anal sphincter. Stool softeners are essential to prevent constipation and
straining during bowel movements, which can cause pain and potential damage
to the repair site. Maintaining bowel regularity and preventing straining is a crucial
aspect of postpartum care for clients with this type of laceration.
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12. An older adult male reporting abdominal pain is admitted to the hospital
from a long term care facility. It has been seven days since his last bowel
movement, and his abdomen is distended, and he just vomited 150 milliliters
of dark brown emesis. In what order should the nurse implement these interventions?
a. Elevate the head of bed
b. Complete focus assessment
c. Offer PRN pain medication
d. Send emesis sample to the lab
Ans>> a. Elevate the head of bed
c. Offer PRN pain medication
b. Complete focus assessment
d. Send emesis sample to the lab
13. What is the primary purpose for initiating nursing interventions that promote good nutrition, rest and exercise, and stress reduction for clients diagnosed with and HIV infection?
a. Increase ability to carry out activities of daily living
b. Promote a feeling of general well-being
c. Prevent spread of infection to others
d. Improve function of the immune system
Ans>> d. Improve function of the immune system
HIV (Human Immunodeficiency Virus) infection attacks the immune system, specifically CD4 cells (T cells), which are crucial for the immune response. The goal of pro-
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moting good nutrition, rest, exercise, and stress reduction is to support and enhance
the function of the immune system in clients with HIV. A strong immune system
can help the body better fight off infections and diseases, including opportunistic
infections associated with advanced HIV/AIDS.
14. A nurse who works in the nursery is attending the vaginal delivery of a term
infant. What action should the nurse complete prior to leaving the delivery
room?
a. Obtain the infants vital signs
b. Observe the instant latching on to the breast
c. Place the ID bands on the infant and mother
d. Administer vitamin K injection
Ans>> c. Place the ID bands on the infant and mother
Placing identification bands on both the infant and the mother is an essential safety
measure to ensure proper identification and matching of mother and baby. This
helps prevent any mix-ups or confusion in the postpartum period. The infant's vital
signs (option a) are typically assessed after birth, but the priority is to ensure proper