HESI EXIT V4 160 Questions and Answers
1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which
nursing intervention is appropriate for this child?
A) Make certain the child is maintained in correct body alignment.
B) Be sure the traction weights touch the end of the bed.
C) Adjust the head and foot of the bed for the child's comfort
D) Release the traction for 15-20 minutes every 6 hours PRN.
The correct answer is A: Make certain the child is maintained in correct body alignment.
2. The nurse is assessing a healthy child at the 2 year check up. Which of the following
should the nurse report immediately to the health care provider?
A) Height and weight percentiles vary widely
B) Growth pattern appears to have slowed
C) Recumbent and standing height are different
D) Short term weight changes are uneven
The correct answer is A: Height and weight percentiles vary widely
3. The parents of a 2 year-old child report that he has been holding his breath whenever he
has temper tantrums. What is the best action by the nurse?
A) Teach the parents how to perform cardiopulmonary resuscitation
B) Recommend that the parents give in when he holds his breath to prevent anoxia
C) Advise the parents to ignore breath holding because breathing will begin as a reflex
D) Instruct the parents on how to reason with the child about possible harmful effects The
correct answer is C: Advise the parents to ignore breath holding because breathing will
begin as a reflex

4. The nurse is assessing a client in the emergency room. Which statement suggests that the
problem is acute angina?
A) "My pain is deep in my chest behind my sternum."
B) "When I sit up the pain gets worse."
C) "As I take a deep breath the pain gets worse."
D) "The pain is right here in my stomach area."
The correct answer is A: "My pain is deep in my chest behind my sternum."
.
5. The nurse is assessing the mental status of a client admitted with possible organic brain
disorder. Which of these questions will best assess the function of the client's recent

memory?
A) "Name the year." "What season is this?" (pause for answer after each question)
B) "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now
continue to subtract 7 from the new number."
C) "I am going to say the names of three things and I want you to repeat them after me:
blue, ball, pen."
D) "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of
it?"
The correct answer is C: "I am going to say the names of three things and I want you to repeat
them after me: blue, ball, pen."
6. In planning care for a 6 month-old infant, what must the nurse provide to assist in the
development of trust?
A) Food
B) Warmth
C) Security
D) Comfort
The correct answer is C: Security
7. A nurse has just received a medication order which is not legible. Which statement best
reflects assertive communication?
A) "I cannot give this medication as it is written. I have no idea of what you mean."
B) "Would you please clarify what you have written so I am sure I am reading it
correctly?"
C) "I am having difficulty reading your handwriting. It would save me time if you would be
more careful."
D) "Please print in the future so I do not have to spend extra time attempting to read your
writing."
The correct answer is B) "Would you please clarify what you have written so I am sure I am
reading it correctly?"

9. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the
nurse enters the room to request something for pain. The nurse should
A) Administer a placebo
B) Encourage increased fluid intake
C) Administer the prescribed analgesia
D) Recommend relaxation exercises for pain control
The correct answer is C: Administer the prescribed analgesia
10. While caring for a toddler with croup, which initial sign of croup requires the nurse's
immediate attention?
A) Respiratory rate of 42
B) Lethargy for the past hour
C) Apical pulse of 54
D) Coughing up copious secretions
The correct answer is A: Respiratory rate of 30
11. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial
assessment, the nurse would anticipate which of the following assessment findings?
A) Lethargy
B) Heat intolerance
C) Diarrhea
D) Skin eruptions
The correct answer is A: Lethargy
12. The emergency room nurse admits a child who experienced a seizure at school. The
father comments that this is the first occurrence, and denies any family history of epilepsy.
What is the best response by the nurse?
A) "Do not worry. Epilepsy can be treated with medications."

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B) "The seizure may or may not mean your child has epilepsy."
C) "Since this was the first convulsion, it may not happen again."
D) "Long term treatment will prevent future seizures."
The correct answer is B: "The seizure may or may not mean your child has epilepsy."
13. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What
nursing diagnosis best applies?
A) Risk for injury
B) Risk for knowledge deficit

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C) Altered thought process
D) Disturbance in self-esteem
The correct answer is A: Risk for injury
14. The nurse is caring for a 10 month-old infant who is has oxygen via mask. It is
important for the nurse to maintain patency of which of these areas?
A) Mouth
B) Nasal passages
C) Back of throat
D) Bronchials
The correct answer is B: Nasal passages
15. The nurse is providing instructions for a client with pneumonia. What is the most
important information to convey to the client?
A) "Take at least 2 weeks off from work."
B) "You will need another chest x-ray in 6 weeks."
C) "Take your temperature every day."
D) "Complete all of the antibiotic even if your findings decrease."
The correct answer is D: "Complete all of the antibiotic even if your findings decrease."
16. When counseling a 6 year old who is experiencing enuresis, what must the nurse
understand about the pathophysiological basis of this disorder?
A) Has no clear etiology
B) May be associated with sleep phobia
C) Has a definite genetic link
D) Is a sign of willful misbehavior
The correct answer is A: Has no clear etiology
17. The nurse is discussing negativism with the parents of a 30 month-old child. How
should the nurse tell the parents to best respond to this behavior?

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A) Reprimand the child and give a 15 minute "time out"
B) Maintain a permissive attitude for this behavior
C) Use patience and a sense of humor to deal with this behavior
D) Assert authority over the child through limit setting
The correct answer is C: Use patience and a sense of humor to deal with this behavior
18. The nurse is talking by telephone with a parent of a 4 year-old child who has
chickenpox. Which of the following demonstrates appropriate teaching by the nurse?
A) Chewable aspirin is the preferred analgesic

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B) Topical cortisone ointment relieves itching
C) Papules, vesicles, and crusts will be present at one time
D) The illness is only contagious prior to lesion eruption
The correct answer is C: Papules, vesicles, and crusts will be present at one time
19. The nurse is assigned to a client who has heart failure . During the morning rounds
the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse
auscultates, crackles bilaterally.
Which nursing intervention should be performed first?
A) Take the client's vital signs
B) Place the client in a sitting position with legs dangling
C) Contact the health care provider
D) Administer the PRN anti anxiety agent
The correct answer is B: Place the client in a sitting position with legs dangling
20. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the
parents to
A) Dress the child warmly to avoid chilling
B) Keep the child away from other children for the duration of the rash
C) Clean the affected areas with tepid water and detergent
D) Wrap the child's hand in mittens or socks to prevent scratching
The correct answer is D: Wrap the child''s hand in mittens or socks to prevent scratching
21. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special
family gatherings?" Which initial response by the nurse would be best?
A) "A recovering person has to be very careful not to lose control, therefore, confine your
drinking just at family gatherings."
B) "At your next AA meeting discuss the possibility of limited drinking with your
sponsor."
C) "A recovering person needs to get in touch with their feelings. Do you want a drink?"
D) "A recovering person cannot return to drinking without starting the addiction process

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C) Family history of breast cancer
D) Uses cocaine on weekends
The correct answer is D: Uses cocaine on weekends
23. A client is receiving nitroprusside IV for the treatment of acute heart failure with
pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this
medication?
A) Potassium
B) Arterial blood gasses
C) Blood urea nitrogen
D) Thiocyanate
The correct answer is D: Thiocyanate
24. A victim of domestic violence tells the batterer she needs a little time away. How
would the nurse expect that the batterer might respond?
A) With acceptance and views the victim’s comment as an indication that their marriage is
in trouble
B) With fear of rejection causing increased rage toward the victim
C) With a new commitment to seek counseling to assist with their marital problems
D) With relief, and welcomes the separation as a means to have some personal time
The correct answer is B: With fear of rejection causing increased rage toward the victim
25. A postpartum mother is unwilling to allow the father to participate in the newborn's
care, although he is interested in doing so. She states, "I am afraid the baby will be
confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's
initial intervention should be what focus?
A) Discuss with the mother sharing parenting responsibilities
B) Set time aside to get the mother to express her feelings and concerns
C) Arrange for the parents to attend infant care classes
D) Talk with the father and help him accept the wife's decision
The correct answer is B: Set time aside to get the mother to express her feelings and concerns

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The correct answer is B: Use oxygen during meals improves gas exchange
27. Which of these parents’ comment for a newborn would most likely reveal an initial
finding of a suspected pyloric stenosis?
A) I noticed a little lump a little above the belly button.
B) The baby seems hungry all the time.
C) Mild vomiting that progressed to vomiting shooting across the room.
D) Irritation and spitting up immediately after feedings.
The correct answer is C: Mild emesis progressing to projectile vomiting
28. The nurse is assessing a child for clinical manifestations of iron deficiency anemia.
Which factor would the nurse recognize as cause for the findings?
A) Decreased cardiac output
B) Tissue hypoxia
C) Cerebral edema
D) Reduced oxygen saturation
The correct answer is B: Tissue hypoxia
29. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic
enzymes along with a diet
A) High in carbohydrates and proteins
B) Low in carbohydrates and proteins
C) High in carbohydrates, low in proteins
D) Low in carbohydrates, high in proteins
The correct answer is A: High in carbohydrates and proteins
30. In evaluating the growth of a 12 month-old child, which of these findings would the
nurse expect to be present in the infant?
A) Increased 10% in height

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B) Ask the client what foods are acceptable or bad
C) Encourage her to eat for healing and strength
D) Schedule the dietitian to meet with the client as soon as possible
The correct answer is B: Ask the client what foods are acceptable
32. The father of an 8 month-old infant asks the nurse if his infant's vocalizations are
normal for his age. Which of the following would the nurse expect at this age?
A) Cooing
B) Imitation of sounds
C) Throaty sounds
D) Laughter
The correct answer is B: Imitation of Sounds
33. The nurse should recognize that physical dependence is accompanied by what
findings when alcohol consumption is first reduced or ended?
A) Seizures
B) Withdrawal
C) Craving
D) Marked tolerance
The correct answer is B: Withdrawal
34. Immediately following an acute battering incident in a violent relationship, the
batterer may respond to the partner’s injuries by
A) Seeking medical help for the victim's injuries
B) Minimizing the episode and underestimating the victim’s injuries
C) Contacting a close friend and asking for help
D) Being very remorseful and assisting the victim with medical care
The correct answer is B: Minimizing the episode and underestimating the victim’s injuries

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HESI Health Assessment Exit Exam Version 4 With Answers (160 Solved Questions)

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