2022 HESI RN Nursing Diagnosis Exit Exam With Answers (160 Solved Questions)

Name: 2022 HESI RN Nursing Diagnosis Exit Exam With Answers (160 Solved Questions)
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HESI EXIT
RN
2022 V3
160
Questions

1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a
nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One
hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the
client’s heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to
reporting the finding to the surgeon. Which action should the nurse implement first?
a. Measure and document the client’s urinary output.
b. Request the client’s reserved unit if packed red blood cells.
c. Prepare the placement of a central venous catheter.
d. Increase the infusion rate of Lactated Ringer’s solution.
2. an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right
pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to
the intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red
blood is measured in the collection chamber. Which intervention should the nurse implement?
a. Add sterile water to the suction control chamber.
b. Give blood from the collection chamber as autotransfusion
c. Manipulate blood in tubing to drain into chamber.
d. Increase wall suction to eliminate fluctuation in water seal.
3. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100
mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is
manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air
of 89%. Which action should the nurse take first?
a. Elevate the foot of the bed.
b. Restrict the client’s fluid.
c. Begin supplemental oxygen.
d. Prepare the client for hemodialysis.

4. A client with Addison’s crisis is admitted for treatment with adrenal cortical supplementation.
Based on the client’s admitting diagnosis, which findings require immediate action by the nurse?
(Select all that apply)
a. Headache and tremors
b. Irregular heart rate
c. Skin hyperpigmentation
d. Postural hypotension
e. Pallor and diaphoresis
5. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding
is the best indicator of hydration that the nurse should report to the healthcare provider?
a. Urine specific gravity is 1.040
b. Systolic blood pressure decreases 10 points when standing.
c. The client denies being thirsty.
d. Skin tenting occurs when the client’s forearm is pinched.
6. After an inservice about electronic health record (EHR) security and safeguarding client
information, the nurse observes a colleague going home with printed copies of client
information in a uniform pocket. Which action should the nurse take?
a. File a detailed incident report with the specific hiring facility.
b. Warn the colleague that their actions are unprofessional.
c. Comment anonymously about the action of a staff discussion board.
d. Communicate the colleague’s actions to the unit charge nurse.

7. The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease
implemented in a rural health clinic. Which outcome indicate the program is effective?
a. At-risk clients received an increased number of routine health screenings.
b. Clients reported having new confidence in making healthy food choices.
c. Clients who incurred disease complications promptly received rehabilitation.
d. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.
8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses
oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is
having increased shortness of breath with respirations at 23 breaths/minute. Which action
should the nurse implement first?
a. Determine if the client is experiencing any anxiety.
b. Auscultate the client’s bilateral lung sounds and oxygen saturation.
c. Notify the healthcare provider about the client’s distress.
d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an
immediate investigation by the nurse?
a. “When I get out of bed quickly, I feel a little dizzy.”
b. “The dressing over my incision feels like it is too tight.”
c. “I’m most comfortable when the head of the bed is raised.”
d. “This IV infusion makes me urinate more often than usual.”

10. An older adult male who is in his early 70’s is admitted to the emergency department because of
a COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing
for endotracheal intubation. The spouse’s wife, who is 30 years younger than the client, asks the
nurse to stop the procedure and provide the nurse a copy of the client’s living will. Which action
should the nurse take?
a. Facilitate a family meeting with the palliative care team.
b. Notify the healthcare provider of the client’s wishes.
c. Place a certified copy of the living will in the client’s record.
d. Alert the nursing staff of the client’s don’t resuscitate status.
11. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose
prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the
client is so obese that the UAP feels unable to safely assist the client in transferring from the bed
to the bedside commode. How should the nurse respond?
a. Determine the client’s level of mobility and need for assistance.
b. Instruct the UAP that all clients deserve equal care.
c. Advice the client to maintain bedrest so that safety can be ensured.
d. Assign another UAP to care for the client.
12. A nurse determines that more than 25% of the students at a middle school are overweight. The
nurse presents the information at the parent-teacher meeting. What action is most important
for the nurse to include in the meeting?
a. Provide information on ways to increase activity for the family.
b. Have several teachers talk about health risks associated with obesity.
c. Distribute a shopping list of suggested healthy snack items.
d. Determine the parents’ degree of concern about their children’s weight.

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13. After several months of chronic fatigue, morning stiffness, and join pain, a young adult is
diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which
education should the nurse provide the client with regard to taking prednisone?
a. Take prednisone doses before meals on an empty stomach.
b. Wear sunglasses when exposed to bright sunlight.
c. If sequential doses are missed, notify the healthcare provider.
d. Schedule a monthly laboratory visit for a complete blood count.
14. The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the
nurse’s immediate attention?
a. A 16-year-old client diagnosed with major depression who refuses to participate in group.
b. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack.
c. An 18-year-old client with antisocial behavior who is being yelled at by other clients
d. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby..
15. The nurse caring for a child with

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17. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty.
Which client report is most important for them to explore further prior to the start of the
procedure?
a. Drank a glass of water in the past 2 hours.
b. Reports left chest wall pain prior to admission.
c. Verbalize a fear of being in a confined space.
d. Experience facial swelling after eating crab.
18. The nurse is assessing a 4-year-old child with eczema. The child’s skin is dry and scaly, and the
mother reports that the child frequently scratches the lesions on the skin to the point of causing
bleeding. Which guideline is indicated for care of this child?
a. Keep the nails trimmed short.
b. Apply baby lotion to the skin twice daily.
c. Bathe the child daily with bath oil.
d. Allow the child to wear only 100% cotton clothing.
19. A new mother on the postpartum unit runs out of the room screaming that her newborn infant’s
crib is empty and the baby is missing. What action should the nurse take first?
a. Determine if the newborn is in the nursery.
b. Activate the lockdown procedure.
c. Ask the mother if any visitors were expected to arrive.
d. Match ID bands of all infants and mothers on

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22. The nurse is developing a plan of care for a client who reports tingling of the feet and who is
newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in
the plan of care for this client?
a. The client will express acceptance of their newly diagnosed health status.
b. The nurse will encourage the client to walk thirty minutes everyday.
c. The client’s blood pressure readings will be less than 160/90 mmHg.
d. The client’s skin on the lower legs will be intact at the next clinical visit.
23. When conducting diet teaching for a client who was diagnosed with hypertension, which food
should the nurse encourage the client to eat? (select all that apply.)
a. . Fruits without sauce
b. Canned soup.
c. Fresh or frozen vegetables without sauce.
d. Cottage cheese.
e. Pickled olives.
24. A client with bacterial meningitis is receiving phenytoin. Which assessment finding indication to
the nurse that the client is experiencing a therapeutic response to the phenytoin?
a. Increased time of ambulation between periods of rest.
b. Decrease in intracranial pressure and cerebral edema.
c.

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27. The charge nurse in an extended care facility is organizing unit activities for the day. Which
action may be safely delegated to the practical nurse (PN)?
a. Measure the client’s body weight each morning.
b. Establish blood pressure parameters for client monitoring
c. Evaluate a staff member providing wound care.
d. Evaluate client teaching through return demonstration.
28. During shift report, the charge nurse receives notice of several problems. Which problem should
the nurse address first?
a. The census report has not been completed.
b. A client’s wife has asked to speak with the charge nurse.
c. One staff member has not reported to work.
d. A bucket of water was spilled in the hallway.
29. An older adult client with chronic emphysema is admitted to the emergency room from home
with acute onset of weakness, palpitations, and vomiting. Which information is most important
for the nurse to obtain during the initial interview?
a. History of smoking over the past 6 months.
b. Sleep patterns during the previous few week.
c. Activity level prior to onset of symptoms.
d. Recent compliance with prescribed medications.
30. The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is
weak and begins coughing while attempting to drink through a straw. Which intervention should
the nurse implement?
a. Assess the client’s oral cavity for ulcerations.
b. Monitor the client when using a straw for liquids.
c. Teach coughing and deep breathing exercises.
d. Request thick nectar liquids for the client.
31. A male client with right-sided weakness calls for assistance with ambulating to the bathroom.
What action should the nurse implement?
a. Bring a bedside commode to

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32. An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia.
The nurse notes that in the evening this client often becomes restless, confused, and agitated.
Which intervention is most important for the nurse to implement?
a. Ask family members to remain with the client in the evening from 1700 to 2100 p.m.
b. Ensure that the client is assigned to a room close to the nurses’ station.
c. Postpone administration of nighttime medications until after 2300 p.m.
d. Administer a prescribed PRN benzodiazepine at the onset of a confused state.
33. The nurse is caring for a client who is having a sickle cell crisis. What intervention should the
nurse include in this client’s plan of care?
a. Ensure adequate IV and oral fluid intake.
b. Provide ice packs to major joint areas.
c. Space analgesics to prevent addiction to narcotics.
d. Re-enforce the importance of nutritional balance.
34. The nurse is teaching a primigravida about preeclampsia. Which finding are indicators of
preeclampsia and should be reported to the healthcare provider? (select all that apply.)
a. Blurred vision
b. Headache.
c. Lack of appetite.
d. Urinary

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2022 HESI RN Nursing Diagnosis Exit Exam With Answers (160 Solved Questions)

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