1. After placing a 36- week- gestation newborn in an isolette and drying the
infant with several blankets, what should the nurse implement next?
a. Place erythromycin ophthalmic ointment in both eyes
2. A client in the third trimester of pregnancy complains of frequent nasal
stiffness and occasional nosebleeds. Her chest circumference has increased
by 5 cm during the pregnancy, and she uses thoracic breathing. Her
diaphragm is elevated and she has an increased costal angle. Which
intervention should the nurse implement?
a. Examine the client for signs of tissue anoxia, such as pallor
3. A terminally ill male hospice client who is at home is showing decreased
awareness of his surroundings. His appetite is poor and he often refuses oral
intake of solids and liquids. For the past several days he has been unable to
get out of bed. Which action should the hospice nurse implement?
a. Teach the family how to assist the client to a wheelchair
4. A woman was admitted yesterday afternoon with severe abdominal pain. Her
pregnancy test and ultrasound were negative, so an exploratory laparotomy
was completed during the night. When coffee ground materials is observed in
the drainage from the nasogastric tube (NGT), which intervention should the
nurse implement?
a. Verify correct placement of the nasogastric tube
5. The nurse is reviewing the laboratory values for a client with acute
pancreatitis who reports of the abdominal pain is not as severe as it was on
admission. Which laboratory test should the nurse review to evaluate the
clients clinical recovery?
a. Lipase
6. While assessing a client who had a laparotomy the previous day, the nurse
notices that 300 mL of dark red fluid has drained from the nasogastric tube in
the last hour. Which action should the nurse take first?
a. Assess the clients level of pain
7. The nurse is reviewing the recommended preventative care for clients with
asthma, chronic bronchitis, and emphysema. Which health care measure is
most important for the nurse to recommend to these clients?
a. Avoid large crowded areas during the colder months of the year
8. The mother of a one-moth-old infant calls the clinic to report that the back of
her infant’s head is flat. How should the nurse respond?
a. Position the infant on the stomach occasionally when awake and
active
9. A woman is brought to the labor and delivery unti after delivering a term
infant and the placenta in the hospital parking lot 10 minutes ago. Which
action should the nurse perform first?
a. Place the infant to the breast for bonding
10. A client has a new prescription for the maximum recommended dosage of
pipercillin/tazobactam for nosocomial pneumonia. The nurse should report
which laboratory finding to the healthcare provider before administering the
prescribed dose?
a. Presence of gram positive bacteria in the sputum
2020 HESI EXIT V3

11. A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating
Kussmaul breathing and has a severe headache along with nausea. Her
arterial blood gases (ABG) are: pH 7.50; PaCO2 30 mmHg; HCO3 24 mEq/L
(24mmol/L). Which assessment finding warrants immediate intervention by
the nurse?
a. Fruity breath
12. When perfomring postural drainage on a client with Chronic Obstructive
Pulmonary disease (COPD), which approach should the nurse use?
a. Expalin that the client may be placed in five positions
13. A young male client with testicular cancer has a living will that describes his
desire that no extraordinary measures be taken to save his life. The
healthcare provider knows the client has a good prognosis and refuses to
write a “do not resuscitate” (DNR) prescription. Which action should the
nurse take?
a. Place a DNR bracelet on the clients arm
14. In observing a clients face, which assessment finding requires the most
immediate intervention by the nurse?
a. Oral mucosa is cyanotic
15. The nurse is assessing a client with cirrhosis and notes that the client has a
positive Babinski reflex. Which action should the nurse take in response to
the finding?
a. Complete a thorough neurological assessment
16. Which action should the nurse take first after obtaining a urine specimen for
culture and sensitivity from an indwelling urinary catheter?
a. Label the container with the client’s identifiers
17. The home health nurse observes an older client with unilateral weakness
place the walker in front of the chair for support while rising to a standing
position. Which action should the nurse take?
a. Instruct the client to use the arms of the chair for support
18. A client with cancer complains of fever, chills, malaise, and headache
following administration of a colony-stimulating factor. Which nursing
intervention is most beneficial in helping to reduce the flu-like symptoms?
a. Monitor lab values for an increase in WBCs
19. Which laboratory value should the nurse review prior to administering the
initial dose of a statin medication?
a. Serum liver enzymes
20. Following a lumbar puncture, a client voices several concerns. Which concern
indicates to the nurse that the client is experiencing a complication of the
procedure?
a. I have a headache that gets worse when I sit up
21. The nurse is caring for a client withdrawing from a fentanyl citrate addiction.
The client receives a prescription for clonidine 0.2 mg PO taken twice daily.
Which action should the nurse take?
a. Advise to sit up slowly from a reclining position

22. A 7-year-old child is admitted to the hospital with a diagnosis of acute
rheumatic fever. In obtaining a health history form the child’s mother, the
recent occurrence of what illness is most significant?
a. Sore throat
23. Following discharge teaching, a client with a duodenal ulcer tells the nurse of
plans to eat plenty of dairy products, such as milk, to help coat and protect
their ulcer. Which is the best follow-up action by the nurse?
a. Review with the client the need to avoid foods that are rich in milk
and cream
24. The nurse assesses a client with cirrhosis and find 4+ pitting edema of the
feet and legs, and massive ascites. Which mechanism contributes to edema
and ascites in clients with cirrhosis?
a. Hypoalbuminemia that results in a decreased colloidal oncotic
pressure
25. The nurse is caring for an adolescent client with an intestinal obstruction
who presents with severe, colicky abdominal pain, nauseas, vomiting, and
abdominal distention. Which pathophysiological mechanism supports the
client’s clinical presentation?
a. A weakened diaphragm with high abdominal pressure
26. An adult who was recently diagnosed with glaucoma tells the nurse, “it feels
like I am driving through a tunnel.” The client expresses great concern about
going blind. Which nursing instruction is most important for the nurse to
provide to this client?
a. Maintain prescribed eye drop regimen
27. The charge nurse is making assignments on a cardiac unit. Which client is
best to assign to a new graduate who is orienting to the unit? A client
a. With atrial fibrillation whose saline lock is infiltrated
28. Penicillin G procaine 240,000 units intramuscularly is prescribed for a 4-
year-old child who has streptococcal respiratory infection. The medication
vial is labeled 1,200,000 units/2mL. How many mL should the nurse
administer?
a. 0.4
29. A client in labor states, “I think my water just broke!” The nurse notes that
the umbilical cord is on the perineum. What action should the nurse perform
first?
a. Place the client in trendelenburg
30. A client who was recently diagnosed with anorexia nervosa collapses at an
outpatient clinic. While taking the blood pressure, the client begins to
demonstrate cloudy consciousness, stupor, and has slurred speech. The nurse
obtains blood glucose of 50 mg/dL, heart rate of 116 beats/minute, and
blood pressure of 88/50 mmHg. Which intervention is most important for
the nurse to implement?
a. Position client with head flat and feet elevated
31. The nurse is planning care for a 16-year-old, who has juvenile idiopathic
arthritis (JIA)> the nurse includes activities to strengthen and mobilize the

2020 HESI Clinical Analysis Exit Exam Version 3 With Answers (129 Solved Questions)

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