Full download please email me stoneklopp@gmail.com
HESI RN EXIT V1 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- mias or changes in cardiac function are
present. This assessment will help guide further interventions and treatment.
Full download please email me stoneklopp@gmail.com
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.
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
Full download please email me stoneklopp@gmail.com
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-inflam- matory
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
c. Explain that there is no indication the fetal heart rate is due to trauma
d. Evaluate the presence of preterm labor by performing a vaginal examina- tion
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
Full download please email me stoneklopp@gmail.com
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 the
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
Full download please email me stoneklopp@gmail.com
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
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
Full download please email me stoneklopp@gmail.com
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 prepar- ing 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 the interview is not
acceptable behavior. This approach respects the client's dignity while maintaining a safe and
appropriate environment.
Full download please email me stoneklopp@gmail.com
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.
Full download please email me stoneklopp@gmail.com
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 inter- ventions?
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 pro- mote
good nutrition, rest and exercise, and stress reduction for clients diag- nosed 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, specifi- cally CD4
cells (T cells), which are crucial for the immune response.The goal of pro- 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.
Full download please email me stoneklopp@gmail.com
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
Full download please email me stoneklopp@gmail.com
identification first. Observing the infant latching on to the breast (option b) and
administering a vitamin K injection (option d) can occur after proper identification is
established.
15. The nurse is preparing a client with an acoustic neuroma for a magnetic resonance
image (MRI). Which client complaint is life threatening and should be reported to the
health care provider immediately?
a. Difficulty with balance
b. Intensifying headache
c. Right ear hearing loss
d. Facial numbness
Ans>> b. Intensifying headache
An intensifying headache in a client with an acoustic neuroma can be indicative of
increased intracranial pressure, which can be life-threatening if not addressed promptly.
Acoustic neuromas, though typically benign, can grow and press on
adjacent brain structures, leading to increased intracranial pressure. This pressure can cause
a severe headache and might lead to serious complications, including brain herniation, if not
treated immediately.
16. A client with chronic kidney disease (CKD) is discharged with a pre- scription for
epoetin alpha subcutaneously. In teaching the client about the medication, the nurse
should emphasize the benefit of increasing which food product in the diet?
a. Iron rich foods
b. High fiber foods
c. Citrus fruits and vegetables
d. Dairy products
Ans>> a. Iron rich foods
Epoetin alpha is a medication used to treat anemia in CKD by stimulating the production of
red blood cells. Iron is essential for the production of hemoglobin, a protein in red blood cells