1. The school nurse is preparing a presentation for an elementary school teacher to inform
them about when a child should be referred to the school clinic for further follow-up.
The teachers should be instructed to report which situations to the school nurse?
(Select all that apply)
a. Refuses to complete written homework assignments
b. Thirst and frequent requests for bathroom breaks
c. Bruises on both knees after the weekend
d. Sunburn with blisters on face, arms, and hands
e. Shaking that changes the child’s handwriting
2. When preparing a child for discharge from the hospital following a cystectomy and a
urinary diversion to treat bladder cancer, which instruction is most important for the
nurse to include in the client’s discharge teaching plan?
a. Report any signs of cloudy urine output
b. Frequently empty bladder to avoid distention
c. Follow instructions for self-care toileting
d. Seek counseling for body image
3. A client with renal lithiasis is receiving morphine sulfate every four hours for pain and
renal colic. Which assessment finding should prompt the nurse to administer PRN dose
of naloxone?
a. Unresponsive to verbal or tactile stimuli
b. Respiratory rate of 12 breaths per minute
c. Statements about visual hallucinations
d. Complaints of increasing flank pain
4. The mother of a 7-month-old brings the infant to the clinic, because the skin in the
diaper area is excoriated and red, but there are no blisters or bleeding. The mother
reports no evidence of watery stools. Which nursing intervention should the nurse
implement?
a. Instruct the mother to change the child’s diaper more often
b. Encourage the mother to apply lotion with each diaper change
c. Ask the mother to decrease the infant’s intake of fruits for 24 hours
d. Tell the mother to cleanse with soap and water at each diaper change
5. The nurse is having difficulty palpating a client’s posterior tibial pulse while the client is
lying in a supine position. Which of the following interventions is best for the nurse to
take?
a. Extend the client’s arm fully while supporting the elbow and attempt to re-
palpate
b. Apply less pressure when palpating over the middle of the dorsum of the foot
c. Use an ultrasound stethoscope, and place behind and below the medial bone
d. Help the client to a prone position with the knee slightly flexed and palpate again
6. The nurse initiates a tertiary prevention program for type 2 diabetes mellitus in a rural
health clinic. Which outcome indicates that the program was effective?
a. Average client scores improved on specific risk factor knowledge tests
b. Only 30% of client did not attend self-management education sessions
c. More than 50% of at-risk clients were diagnosed earl in the disease process

d. Client who developed disease complications promptly received rehabilitation
7. A client is recovering in the critical care until following a cardia catheterization. IV
nitroglycerin and heparin are infusing. The client is sedated but responds to verbal
instructions. After changing positions, the client complains of pain at the right going
insertion site. What action should the nurse implement?
a. Stimulate the client to take deep breaths
b. Evaluate the integrity of the IV insertion site
c. Assess distal lower extremity capillary refill
d. Check femoral site for hematoma formation
8. A 7-year old is admitted to the hospital with persistent vomiting, and nasogastric tube
attached to low intermittent suction is applied. Which finding is most important for the
nurse to report to the healthcare provider?
a. Shift intake of 640mL IV fluids plus 30mL PO ice chips
b. Serum pH of 7.45
c. Serum potassium of 3.0 mg/dl
d. Gastric output of 100 mL in the last 8 hours
9. A morbidly obese client is scheduled for gastric bypass surgery. The client completes the
required preoperative nutritional counseling and signs the operative permit. To
promote effective discharge planning, which intervention is most important for the
nurse to implement?
a. Discuss small, low fat, low sugar meal preparation techniques
b. Advise the client to arrange for dietary counseling after being discharged
c. Encourage the client to keep a daily diary for two weeks
d. Suggest that the client’s spouse do the family grocery shopping
10. The nurse is admitting a client from the post-anesthesia unit to the postoperative
surgical care unit. Which prescription should the nurse implement first?
a. Cefazolin 1-gram IVPB q6 hours
b. Complete blood cell count (CBC) in AM
c. Straight catheterization if unable to void
d. Advance from clear liquid as tolerated
11. Which needle should the nurse use to administer IV fluids via c lient’s implanted port?
a. 5cc syringe & needle
b. Butterfly stick
c. **click on the image that isn’t any of the other options**
d. Vacutainer
12. An older client is referred to a rehabilitation facility following a cerebrovascular accident
(CVA). The client is aphasic with left-sided paresis and is having difficulty swallowing.
Which intervention is most important for the nurse to include in the client’s plan of
care?
a. Use pictures and gestures to communicate
b. Arrange for daily home care assistance
c. Facilitate a consultation for speech therapy
d. Initiate passive range of motion exercises

13. A client has had several episodes of clear, watery diarrhea that started yesterday. What
action should the nurse implement?
a. Assess the client for the presence of hemorrhoids
b. Administer a prescribed PRN antiemetic
c. Check the client’s hemoglobin level
d. Review the client’s current list of medications
14. A mother runs into the emergency department with a toddler in her arms and tells the
nurse that her child got into some cleaning products. The child smells of chemicals on
hands, face, and on the front of the child’s clothes. After ensuring the airway is patent,
what action should the nurse implement first?
a. Call poison control emergency number
b. Determine type of chemical exposure
c. Obtain equipment of for gastric lavage
d. Assess child for altered sensorium
15. When should the nurse conduct an Allen’s test?
a. Prior to attempting a cardiac output calculation
b. When pulmonary artery pressures are obtained
c. Just before arterial blood gasses are drawn peripherally
d. To assess for presence of deep vein thrombosis in the leg
16. A nurse with 10-years’ experience working in the emergency department is reassigned
to the perinatal unit to work an 8-hour shift. Which client is best to assign to this nurse?
a. A mother with an infected episiotomy
b. A client who is leaking clear fluid
c. A client at 28-weeks’ gestation in pre-term labor
d. A mother who just delivered a 9-pound baby
17. A 300mL unit of packed red blood cells is prescribed for a client with heart failure (HF)
who has 3+ pitting edema, shortness of breath with any activity, and cracked in both
lung bases. At what rate should the nurse administer the blood?
a. 150 mL/hour
b. 75 mL/hour
c. 300 mL/hour
d. 50 mL/hour
18. The nurse enters the room of the client with Parkinson's disease who is taking carbidopa
levodopa. The client is arising slowly from the chair while the unlicensed assistive
personnel (UAP) stands next to the chair. What action should the nurse take?
a. Tell the UAP to assist the client in moving more quickly
b. Offer PRN LG 6 to reduce painful movement
c. Affirm that the client should arise slowly from the chair
d. Demonstrate how to help the client move more efficiently
19. Which assessment is more important for the nurse to include in the daily plan of care for
a client with a burnt extremity?
a. Range of motion
b. Distal pulse intensity
c. Extremity sensation

d. Presence of exit exudate
20. Client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous
graft in the right arm is no longer available to use for hemodialysis. The client has lost
weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/ dL.
Which intervention is the priority for the nurse to implement?
a. Instruct the client to continue to follow the prescribed rigid fluid restriction
amount
b. evaluate pat and see of the AV graft for resumption of hemodialysis
c. ensure the client receives frequent small meals containing complete proteins
d. recommend the use of support stockings to enhance venous return
21. An older adult client with systemic inflammatory response syndrome (SIRS) has a
temperature of 101.8 F (38.8 C), heart rate of 110 beats/minute, and a respiratory rate
of 24 breaths/minute. Which additional finding is most important to report to the health
care provider?
a. Capillary glucose reading of 110 mg/dL (6.1 mmol/L SI)
b. serum creatine of 2.0 mg/dL (176.8 micromol/L SI)
c. Hemoglobin of 12 g/dL (120 g/dL SI)
d. blood pressure of 134/88 mm hg
22. the nurse completes auscultation of the thoracic region of an older adult client. Which
finding is considered normal for this older adult client?
a. High pitched wheezing
b. Hyperresonance
c. medium crackles
d. vesicular sounds
23. a client who is admitted for primary hypothyroidism has early signs of myxedema coma.
In assisting the client, in which sequence should the nurse has completes these actions?
(Rank the first action at the top with the remainder in descending order)
Step 1. observe breathing patterns
Step 2. assess blood pressure
Step 3. measure body temperature
Step 4. palpate for pedal edema
24. What is the primary goal when planning nursing care for a client with degenerative joint
disease (DJD)?
a. achieve satisfactory pain control
b. obtain adequate rest and sleep
c. improve stress management skills
d. reduce risk of infection
25. the home care nurse provides self-care instructions for a client with chronic venous
insufficiency caused by deep vein thrombosis. Which instructions should the nurse
include in the client's discharge teaching plan? (Select all that apply)
a. Avoid prolonged standing or sitting
b. use recliner for long periods of sitting
c. continue wearing elastic stockings
d. maintain the bed flat while sleeping

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2021-2022 HESI RN Child Care Exit Exam With Answers (160 Solved Questions)

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