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ATI RN HESI EXIT Exam Questions and Level A+ Answers
1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? a- Remind the client that it is also important to switch to decaffeinated coffee and tea. b- Suggest that the client also plan to eat frequent small meals to reduce discomfort c- Review with the client the need to avoid foods that are rich in milk and cream. d- Reinforce this teaching by asking the client to list a dairy food that he might select. Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should be avoided. 2. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?
a- Blindness secondary to cataracts b- Acute kidney injury due to glomerular damage c- Stroke secondary to hemorrhage d- Heart block due to myocardial damage Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled hypertension.
3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? a- Ensure that the UAP has placed the pillows effectively to protect the client. b- Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. a- Assume responsibility for placing the pillows while the UAP completes another task. b- Ask the UAP to use some of the pillows to prop the client in a side lying position. Rationale: The nurse should instruct the UAP to pad the side rails with soft blankest because the use of pillows could result in suffocation and would need to be removed at the onset of the seizure. The nurse can delegate paddling the side rails to the UAP 4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?
Rationale: Suctioning helps to clear secretions and maintain an open airway, which is critical.
7. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client‟s respiratory rate is 14 breaths / minute. What action should the nurse implement? a- Encourage the client to take deep breaths b- Remove the mask to deflate the bag c- Increase the liter flow of oxygen d- Document the assessment data Rational: reservoir bag should not deflate completely during inspiration and the client‟s respiratory rate is within normal limits. 8. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first? a- Give the client 4 ounces of orange juice b- Call 911 to summon emergency assistance c- Check the client for lacerations or fractures d- Asses clients blood sugar level Rationale: After the client falls, the nurse should immediately assess for the possibility of injuries and provide first aid as needed 9. At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? a- Ensure preoperative lab results are available
b- Start prescribed IV with lactated Ringer‟s c- Inform the anesthesia care provider d- Contact the client‟s obstetrician. Rationale: Surgical preoperative instruction includes NPO after midnight the day of surgery to decrease the risk of aspiration should vomiting occur during anesthesia. While it is possible the C-section will be done on schedule or rescheduled for later in the day, the anesthesia provider should be notified first.
10. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first? a- Side the stethoscope across the sternum. b- Move the stethoscope to the mitral site c- Listen with the bell at the same location d- Observe the cardiac telemetry monitor Rationale: The nurse uses the bell of the stethoscope to hear low-pitched sounds such as S3 and S4. The nurse listens at the same site using the diaphragm the diaphragm and bell before moving systematically to the next sites. 11. A 66 - year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs? a- Woman, Infant, and Children program b- Medicaid c- Medicare d- Consolidated Omnibus Budget Reconciliation Act provision. Rationale: Title XVII of the social security Act of 1965 created
analgesic, and hydration.
14. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? a- Auscultate for renal bruits b- Obtain a clean catch mid-stream specimen c- Use a dipstick to measure for urinary ketone d- Begin to strain the client‟s urine. Rationale: This elderly is experiencing symptoms of urinary tract infection. The nurse should obtain a clean catch mid-stream specimen to determine the causative agent so an anti-infective agent can be prescribed. 15. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child‟s dietary restrictions. Which foods are contraindicated for this child? a- Wheat products b- Foods sweetened with aspartame. c- High fat foods d- High calories foods. Rationale: Aspartame should not be consumed by a child with PKU because ut is converted to phenylalanine in the body. Additionally, milk and milk products are contraindicated for children with PKU. 16. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 - minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?
a- Ask a more experience nurse to perform that scrub since it is the first time of the day b- Validate the nurse is implementing the OR policy for surgical hand scrub c- Inform the nurse that hand scrubs should be 3 minutes between cases. d- Direct the nurse to continue the surgical hand scrub for a 5 - minute duration. Rationale: The surgical hand scrub should last for 5 to 10 mints, so the nurse should be directed to continue the vigorous scrub using a reliable agent for the total duration of 5 mints. It is not necessary to reassign staff (A). The length of the hand scrub and subsequent scrubs during the day require the same process for the same amount of time, (B and C)
17. Which breakfast selection indicates that the client understands the nurse‟s instructions about the dietary management of osteoporosis? a- Egg whites, toast and coffee. b- Bran muffin, mixed fruits, and orange juice. c- Granola and grapefruit juice d- Bagel with jelly and skim milk. Rationale: D includes dairy products which contain calcium and does not include any foods that inhibit calcium absorption. The primary dietary implication of osteoporosis is the need for increased calcium and reduction in foods that decrease calcium absorption, such as caffeine and excessive fiber. 18. The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a
athlete‟s foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement.” What instruction should the nurse provide? a- Antibiotics take two weeks to become effective against infections such as athlete‟s foot. b- Continue using the ointment for a full week, even after the symptoms disappear. c- Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration. d- Stop using the ointment and encourage complete drying of the feet and wearing clean socks. Rationale: Athlete‟s foot (tinea pedi) is a fungal infection that afflicts the feet and causes scaliness and cracking of the skin between the toes and on the soles of the feet. The feet should be ventilated, dried well after bathing, and clean socks should be placed on the feet after bathing. Antifungal ointments may be prescribed, but antibiotic ointments are not useful.
21. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences a- Palpitations and shortness of breath b- Bradycardia and constipation c- Lethargy and lack of appetite d- Muscle cramping and dry, flushed skin Rationale: An overdose of thyroid preparation generally manifests symptoms of an agitated state such as tremors, palpitations, shortness of breath, tachycardia, increased appetite, agitation, sweating and diarrhea.
22. A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? a- Determine the client‟s level of orientation and cognition b- Assess distal pulses and signs of peripheral edema c- Obtain a list of medications taken for cardiac history. d- Ask the client about exposure to environmental heat. Rationale: The client is presenting with signs of digitalis toxicity. A list of medication, which is likely to include digoxin (Lanoxin) for heart failure, can direct further assessment in validating digitalis toxicity with serum labels greater than 2 mg/ml that is contributing to client‟s presenting clinical picture. 23. The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.) a- 75 Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour 24. The pathophysiological mechanisms are responsible for ascites related to liver failure? (Select all that apply) a- Bleeding that results from a decreased production of the body‟s clotting factors b- Fluid shifts from intravascular to interstitial area due to decreased serum protein c- Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen d- Increased circulating aldosterone levels that increase sodium and water retention
27. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? a- Auscultate the client's bowel sounds b- Observe for edema around the ankles c- Measure the client‟s capillary glucose level d- Count the apical and radial pulses simultaneously Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes constipation, so it is most important to Auscultate the client's bowel sounds 28. A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants “no heroic measures” taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement? a- Ask the client to discuss “do not resuscitate” with her healthcare provider 29. A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? a- Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour b- Continue the full strength feeding after decreasing the rate of infusion to 25 ml/hr. c- Maintain the present feeding until diarrhea subsides and the begin the next new prescription. d- Withhold any further feeding until clarifying the prescription with healthcare provides.
Rationale: Diluting the formula can help alleviate the diarrhea. Diarrhea can occur as a complication of enteral tube feeding and can be due to a variety of causes including hyperosmolar formula.
30. A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask? a- “Is there a history of female baldness in your family?” b- “Are you under any unusual stress at home or work?” c- “Do you work with hazardous chemicals?” d- “ Have you noticed any changes in your fingernails?” Rationale: The pattern of reported manifestations is suggestive of hypothyroidism. A question about the fingernails adds data to the clinical picture. 31. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? a- Bruises on arms and legs b- Round and tight abdomen c- Pitting edema in lower legs d- Capillary refill of 8 seconds Rationale: The client is bleeding and hypovolemia is likely. Capillary refill is greater than 3 to 5 seconds indicates poor perfusion and requires immediate attention 32. After the nurse witnesses a preoperative client sign the surgical
34. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? a- Call the radiology department b- Reinsert the implant into the vagina c- Apply double gloves to retrieve the implant for disposal. d- Place the implant in a lead container using long-handled forceps Rationale: Solid or sealed radiation sources, such as Cesium which is removed after treatment, are inserted into an applicator or cervical implant to emit continuous, low energy radiation for adjacent tumor tissues. If the radiation source or the applicator become dislodged long- handled forceps should be used to retrieve the radiation implant to prevent injury due to direct handling. The applicator is then placed in the lead container. 35. The client with which type of wound is most likely to need immediate intervention by the nurse? a- Laceration b- Abrasion c- Contusion d- Ulceration Rationale: A laceration is an open wound whose edges are often jagged and whose tissue are torn apart that is produced by the tearing of soft body tissue, placing the client at risk for bleeding, so this type of wound is likely to require the most immediate nursing intervention. A laceration wound is often contaminated with bacteria and debris from whatever object caused the cut. 36. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the
highest priority for inclusion in this client‟s plan of care? a- Record urine output every hour b- Monitor blood pressure frequently c- Evaluate neurological status d- Maintain seizure precautions Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-threatening hypertension. The tumor is malignant in 10% of cases but may be cured completely by surgical removal. Although pheochromocytoma has classically been associated with 3 syndromes—von Hippel-Lindau (VHL) syndrome, multiple endocrine neoplasia type 2 (MEN 2), and neurofibromatosis type 1 (NF1)—there are now 10 genes that have been identified as sites of mutations leading to pheochromocytoma.
37. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? a- To reduce abdominal pressure on the diaphragm b- to promote retraction of the intercostal accessory muscle of respiration c- to promote bronchodilation and effective airway clearance d- to decrease pressure on the medullary center which stimulates breathing Rationale: a semi-sitting position is the best position for matching ventilation and perfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing. 38. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal
40. An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? a- obtain a serum potassium level b- administer the client's usual dose of insulin c- assess pupillary response to light d- Start an intravenous (IV) infusion of normal saline Rationale: The nurse should first start an intravenous infusion of normal saline to replace fluids and electrolytes because the client has been vomiting, and it is unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting, and abdominal cramping are all suggestive of hyperglycemia, which also contributes to diuresis and fluid electrolyte imbalance. 41. A client who received multiple antihypertensive medications experiences syncope due to a drop-in blood pressure to 70/40. What is the rationale for the nurse‟s decision to hold the client‟s scheduled antihypertensive medication? a- Increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure b- The antagonistic interaction among the various blood pressure medications has reduced their effectiveness c- The additive effect of multiple medications has caused the blood pressure to drop too low. d- The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension. Rationale: When medication with a similar action are administered, an additive effect occurs that is the sum of the effects of each of the
medication. In this case, several medications that all lower the blood pressure, when administer together, resulted in hypotension.
42. Which client is at the greatest risk for developing delirium? a- An adult client who cannot sleep due to constant pain. b- an older client who attempted 1 month ago c- a young adult who takes antipsychotic medications twice a day d- a middle-aged woman who uses a tank for supplemental oxygen Rationale: Client who are in constant pain ad have difficulty sleeping or resting are at high risk for delirium. Supplemental oxygen may cause confusion. B is taking medication so is not at high risk of delirium. 43. Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? a- Reduce risks factors for infection b- Administer high flow oxygen during sleep c- Limit fluid intake to reduce secretions d- Use diaphragmatic breathing to achieve better exhalation Rationale: Interventions aimed at reducing the risk factors of infections should be included in the plan of care COPD client are at particular risk for respiratory infection. Prevention and early detection of infections are necessary. 44. Which location should the nurse choose as the best for beginning a screening program for hypothyroidism? a- A business and professional women's group. b- An African-American senior citizens center c- A daycare center in a Hispanic neighborhood
