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HESI MILESTONE EXIT EXAM V2-WITH 100%
ACCURATE SOLUTIONS- 2024 - 2025
HESI Exit V
- The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4year-old child?
the air
A) "I strap the infant car seat on the front seat to face backwards."
B) "I place my infant in the middle of the living room floor on ablanket to play with my 4 year old while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little buttocksstuck up in
while the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old abottle in
the kitchen
while I make supper."
The correct answer is D: "I have the four year-old hold andhelp feed the four month-old a bottle in the kitchen
- Upon completing the admission documents, the nurse learns that the87 year-old client A) Record the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
D) Refer this issue to the unit secretary
does not have an advance directive. What action should the nurse take?
The correct answer is B: Give information about advance directives
- A nurse administers the influenza vaccine to a client in a clinic. Within15 minutes
after
the immunization was given, the client complains of itchy and wateryeyes, increased anxiety, and difficulty breathing. The nurse expects that the first action inthe sequence of
care for this client will be to
A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered
The correct answer is B: Administer epinephrine 1:1000 asordered.
- Which of these children at the site of a disaster at a child day carecenter would the A) An infant with intermittent bulging anterior fontanel betweencrying episodes
B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with 1 lower leg fracture and the other leg with anupper leg fracture
D) A school-age child with singed eyebrows and hair on the arms The correct answer is B: A toddler with severe deep abrasions over 98% of the body.
triage nurse put in the "treat last" category?
- When admitting a client to an acute care facility, an identificationbracelet is sent up A) Change whichever item is incorrect to the correct information
B) Use the bracelet and admission form until a replacement issupplied
C) Notify the admissions office and wait to apply the bracelet
D) Make a corrected identification bracelet for the client
with the admission form. In the event these do not match, the nurse’sbest action is to
- Following change-of-shift report on an orthopedic unit, which clientshould the nurse A) 16 year- old who had an open reduction of a fractured wrist 10hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motor cycleaccident
C) 72 year-old recovering from surgery after a hip replacement 2hours ago
D) 75 year-old who is in skin traction prior to planned hip pinningsurgery. The correct answer is C: 72 year-old recovering from surgery after ahip replacement 2 hours ago
see first?
- A nurse observes a family member administer a rectal suppository byhaving the client lie on the left side for the administration. The family memberpushed the suppository until the finger went up to the second knuckle. After 10minutes the client A) Why don’t we now have the client turn back to the left side.
B) That was done correctly. Did you have any problems with theinsertion?
C) Let’s check to see if the suppository is in far enough.
was told by the family member to turn to the right side and the client didthis. What is the
appropriate comment for the nurse to make?
D) Did you feel any stool in the intestinal tract?
The correct answer is B: That was done correctly. Did youhave any problems with the insertion?
- A client with a diagnosis of Methicillin resistant Staphylococcus aureus(MRSA) has A) airborne precautions
B) droplet precautions
C) contact precautions
D) compromised host precautions
died. Which type of precautions is the appropriate type to use whenperforming postmortem care?
The correct answer is C: contact precautions
- The nurse is reviewing with a client how to collect a clean catch urinespecimen. Which sequence is appropriate teaching? A) Void a little, clean the meatus, then collect specimen
B) clean the meatus, begin voiding, then catch urine stream
C) Clean the meatus, then urinate into container
D) Void continuously and catch some of the urine
The correct answer is B: clean the meatus, begin voiding,then catch urine stream
- The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40mg every day. Which of these foods would the nurse reinforce for the client to eat atleast daily? A) spaghetti
B) watermelon
C) chicken
D) tomatoes
The correct answer is B: watermelon
- A nurse is stuck in the hand by an exposed needle. What immediateaction should the
nurse take?
A) Look up the policy on needle sticks
B) Contact employee health services
C) Immediately wash the hands with vigor
D) Notify the supervisor and risk management
The correct answer is C: Immediately wash the hands withvigor
- As the nurse observes the student nurse during the administration ofa narcotic analgesic IM injection, the nurse notes that the student begins to give themedication without first aspirating. What should the nurse do? A) Ask the student: "What did you forget to do?”
B) Stop. Tell me why aspiration is needed.
A) An admission at the change of shifts with atrial fibrillation andheart failure - PN
B) Client who had a major stroke 6 days ago - PN nursing student
C) A child with burns who has packed cells and albumin IV running -charge
D) An elderly client who had a myocardial infarction a week ago -
the nurse manager?
nurse
UAP
The correct answer is A: An admission at the change ofshifts with atrial fibrillation and heart failure - PN
- A mother brings her 3 month-old into the clinic, complaining that thechild seems to A) Increased temperature and lethargy
B) Restlessness and increased mucus production
C) Increased sleeping and listlessness
D) Diarrhea and poor skin turgor
be spitting up all the time and has a lot of gas. The nurse expects to findwhich of the following on the initial history and physical assessment?
The correct answer is B: Restlessness and increased mucus production
- As the nurse takes a history of a 3 year-old with neuroblastoma, whatcomments by A) "The child has been listless and has lost weight."
B) "The urine is dark yellow and small in amounts."
C) "Clothes are becoming tighter across her abdomen."
D) "We notice muscle weakness and some unsteadiness."
the parents require follow-up and are consistent with the diagnosis?
The correct answer is C: "Clothes are becoming tighteracross her abdomen."
- A 16 year-old enters the emergency department. The triage nurseidentifies
A) Ask the teenager to wait until a parent or legal guardian can becontacted
B) Withhold treatment until telephone consent can be obtained fromthe partner
C) Refer the teenager to a community pediatric hospital emergencydepartment
that this
teenager is legally married and signs the consent form for treatment.
What would be the
appropriate action by the nurse?
D) Proceed with the triage process in the same manner as any adult
client
The correct answer is D: Proceed with the triage process inthe same manner as any adult client
- A newly admitted elderly client is severely dehydrated. When planningcare for this client, which task is appropriate to assign to an unlicensed assistivepersonnel A) Converse with the client to determine if the mucous membranesare impaired
B) Report hourly outputs of less than 30 ml/hr
C) Monitor client's ability for movement in the bed
D) Check skin turgor every 4 hours
(UAP)?
The correct answer is B: Report output of less than 30 ml/hr
- The nurse has admitted a 4 year-old with the diagnosis of possiblerheumatic fever. A) Our child had chickenpox 6 months ago.
B) Strep throat went through all the children at the day care lastmonth.
C) Both ears were infected over 3 months age.
D) Last week both feet had a fungal skin infection.
Which nursing diagnosis should have priority?
The correct answer is A: Pain related to ischemia
- The provisions of the law for the Americans with Disabilities Actrequire nurse A) Maintain an environment free from associated hazards
B) Provide reasonable accommodations for disabled individuals
C) Make all necessary accommodations for disabled individuals
D) Consider both mental and physical disabilities The correct answer is B: Provide reasonable accommodations for disabled individuals
managers to
- A 42 year-old male client refuses to take propranolol hydrochloride(Inderal) as prescribed. Which client statement s from the assessment data is likely toexplain his
A) "I have problems with diarrhea."
B) "I have difficulty falling asleep."
C) "I have diminished sexual function."
D) "I often feel jittery."
noncompliance?
The correct answer is C: "I have diminished sexual function."
- A school-aged child has had a long leg (hip to ankle) synthetic castapplied 4 hours
A) ”I will keep the cast for the next day uncovered to preventburning of the skin."
B) ”I can apply an ice pack over the area to relieve itching inside the
C) ”The cast should be propped on at least 2 pillows when my child
D) ”I think I remember that standing cannot be done until after 72hours." The correct answer is D: "I think I remember that standingcannot be done until after 72 hours."
ago. Which statement from the mother indicates that teaching has beeninadequate?
cast."
is lying down."
- Which statement best describes time management strategies appliedto the role of a A) Schedule staff efficiently to cover the needs on the managed unit
B) Assume a fair share of direct client care as a role model
C) Set daily goals with a prioritization of the work
D) Delegate tasks to reduce work load associated with direct careand meetings
nurse manager?
The correct answer is C: Set daily goals with a prioritizationof the
work
- The pediatric clinic nurse examines a toddler with a tentativediagnosis of A) Lymphedema and nerve palsy
B) Hearing loss and ataxia
C) Headaches and vomiting
D) Abdominal mass and weakness
neuroblastoma. Findings observed by the nurse that is associated withthis problem include which of these?
The correct answer is D: Abdominal mass and weakness
- A 15 year-old client has been placed in a Milwaukee Brace. Whichstatement
A) "I will only have to wear this for 6 months."
B) "I should inspect my skin daily."
within the hearing of others. The employee does not respond to thehealth care provider's
complaints. The nurse manager's next action should be to
behavior."
D) Request an immediate private meeting with the health careprovider and staff nurse
The correct answer is D: Request an immediate privatemeeting with the health care provider and staff nurse
- A client is admitted to a voluntary hospital mental health unit due tosuicidal ideation.
The client has been on the unit for 2 days and now states “I demand to bereleased now!” The appropriate action is for the nurse to
A) You cannot be released because you are still suicidal.
B) You can be released only if you sign a no suicide contract.
C) Let’s discuss your decision to leave and then we can prepare youfor discharge.
D) You have a right to sign out as soon as we get an order from thehealth care provider's discharge order.
The correct answer is C: Let’s discuss your decision to leaveand then we can prepare you for discharge.
- A client is admitted with infective endocarditis (IE). Which symptomwould alert the A) Dyspnea
B) Heart murmur
C) Macular rash
D) Hemorrhage
nurse to a complication of this condition?
The correct answer is B: Heart murmur Large, soft, rapidly developing vegetations attach to the heart valves.
- A nurse admits a premature infant who has respiratory distresssyndrome. A) Stabilize thermoregulation
B) Maintain alveolar surface tension
C) Begin normal pulmonary blood flow
D) Regulate intra cardiac pressure
In planning
care, nursing actions are based on the fact that the most likely cause ofthis problem stems from the infant's inabilityto
The correct answer is B: Maintain alveolar surface tension
- An 18 year-old client is admitted to intensive care from the emergency room
following a diving accident. The injury is suspected to be at the level ofthe 2nd cervical
A) Response to stimuli
B) Bladder control
C) Respiratory function
D) Muscle weakness
vertebrae. The nurse's priority assessment should be
The correct answer is C: Respiratory function
- The nurse is caring for a client who was successfully resuscitated froma pulseless dysrhythmia. Which of the following assessments is CRITICAL for thenurse to include A) Hourly urine output
B) White blood count
C) Blood glucose every 4 hours
D) Temperature every 2 hours
The correct answer is C: Check the blood pressure of a 2hours post operative client
- A child is injured on the school playground and appears to have afractured leg. The
first action the school nurse should take is
A) Call for emergency transport to the hospital
B) Immobilize the limb and joints above and below the injury
C) Assess the child and the extent of the injury
D) Apply cold compresses to the injured area
The correct answer is C: Assess the child and the extent ofthe injury
- When interviewing the parents of a child with asthma, it is mostimportant to gather A) Household pets
B) New furniture
C) Lead based paint
D) Plants such as cactus
what information about the child's environment?
The correct answer is A: Household pets
- An 80 year-old client admitted with a diagnosis of possible cerebralvascular accident A) Slurred speech
B) Incontinence
C) Muscle weakness
D) Rapid pulse
has had a blood pressure from 180/110 to 160/100 over the past 2 hours.
The nurse has
also noted increased lethargy. Which assessment finding should the nursereport immediately to the health care provider?
The correct answer is A: Slurred speech
- A 3 year-old child is brought to the clinic by his grandmother to beseen for "scratching his bottom and wetting the bed at night." Based on thesecomplaints, the nurse would initially assess for which problem? A) Allergies
B) Scabies
C) Regression
D) Pinworms
The correct answer is D: Pinworms
- A 72 year-old client with osteomyelitis requires a 6 week course of intravenous
antibiotics. In planning for home care, what is the most important actionby the nurse?
A) Investigating the client's insurance coverage for home IV antibiotic therapy
B) Determining if there are adequate hand washing facilities in the
C) Assessing the client's ability to participate in self care and/or the
D) Selecting the appropriate venous access device
home
reliability of a
caregiver
The correct answer is C: Assessing the client''s ability to participate in self care and/or the reliability of a caregiver
- The mother of a child with a neural tube defect asks the nurse whatshe can do to decrease the chances of having another baby with a neural tube defect. A) "Folic acid should be taken before and after conception."
B) Place client on a clear liquid diet
C) Tilt head back to facilitate swallowing reflex
D) Offer finger foods such as crackers or pretzels
The correct answer is A: Position client in upright positionwhile eating
- The nurse explains an autograft to a client scheduled for excision of askin tumor. A) a tissue bank."
B) a pig."
C) my thigh."
D) synthetic skin."
The
nurse knows the client understands the procedure when the client says, "Iwill receive tissue from…
The correct answer is C: my thigh."
- The nurse is caring for a newborn with tracheoesophageal fistula. A) Risk for dehydration
B) Ineffective airway clearance
C) Altered nutrition
D) Risk for injury
Which nursing diagnosis is a priority?
The correct answer is B: Ineffective airway clearance
- A client has been hospitalized after an automobile accident. A full legcast was applied in the emergency room. The most important reason for the nurseto elevate the casted leg is to A) Promote the client's comfort
B) Reduce the drying time
C) Decrease irritation to the skin
D) Improve venous return
The correct answer is D: Improve venous return
- During the initial home visit a nurse is discussing the care of a newlydiagnosed client
A) Leave a book about relaxation techniques
B) Write out a daily exercise routine for them to assist the client to
C) List actions to improve the client's daily nutritional intake
D) Suggest communication strategies
with Alzheimer's disease with family members. Which of theseinterventions would be
most helpful at this time?
do
The correct answer is D: Suggest communication strategies
- The nurse is teaching a client with non-insulin dependent diabetesmellitus about the A) Maintain previous calorie intake
B) Keep a candy bar available at all times
C) Reduce carbohydrates intake to 25% of total calories
D) Keep a regular schedule of meals and snacks
prescribed diet. The nurse should teach the client to
The correct answer is D: Keep a regular schedule of mealsand snacks
- The mother of a 2 month-old baby calls the nurse 2 days after the firstDTaP, IPV, Hepatitis B and HIB immunizations. She reports that the baby feels verywarm, cries inconsolably for as long as 3 hours, and has had several shaking spells. Inaddition to referring her to the emergency room, the nurse should document thereaction on the baby's record and expect which immunization to bemost A) DTaP
B) Hepatitis B
C) Polio
