Nclex Practice Test - Review For Hesi Exit Exam Study Guide
Fundamentals of Nursing (Ivy Tech Community College of Indiana)
Practice Hesi Exam
1. What instruction should the nurse include in the discharge teaching plan of a client who had a
cataract extraction today?
a. Sexual activities may be resumed upon return home
b. Light housekeeping is permitted but avoid heavy lifting
c. Use a metal eye shield on operative eye during the day
d. Administer eye ointment before applying eye drops
Answer: b. Light housekeeping is permitted but avoid heavy lifting
2. A male adult comes to the urgent care clinic 5 days after being diagnose with influenza. He is
short of breath, febrile, and coughing green colored sputum. Which intervention should the nurse
implement first?
a. Obtain a sputum sample for culture
b. Check his oxygen saturation level
c. Administer an oral antipyretic
d. Auscultate bilateral lung sound
Answer: a. Obtain a sputum sample for culture
3. An elder male client tells the nurse that he is losing sleep because he has to get up several
times at night to go to the bathroom that he has trouble starting his urinary stream and that he
does not feel like his bladder is ever completely empty. Which intervention should the nurse
implement?
a. collect a urine specimen for culture analysis
b. obtain a fingerstick blood glucose level
c. palpate the bladder above the symphysis pubis
d. review the client fluid intake
Answer: c. palpate the bladder above the symphysis pubis
4. An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection
(UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum
laboratory value warrants the most immediate intervention by the nurse?
a. blood ph of 7.30
b. glucose of 350 mg /dl
c. white blood cell count of 15000mm
d. potassium of 2.5 meq/l
Answer: d. potassium of 2.5 meq/l
5. A client with sickle cell anemia develops a fever during the last hour of administration of a
unit of packed red blood cell. When notifying the healthcare provider what information should
the nurse provide first using the SBAR communication process?
a. explain specific reason for urgent notification
b. preface the report by stating the clients name and admitting diagnosis
c. communicate the pre-transfusion temperatures
d. optain prn prescription for acetaminophen for fever 101°C
Answer: a. explain specific reason for urgent notification
6. An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to aids.
While hospitalize he receives IV pentamidine isethionate therapy. In preparing this client for
discharge what important aspect regarding his medication therapy should the nurse explain?
a. AZT therapy must be stopped when IV aerosol pentamidine is being used.
b. IV pentamidine will be given until oral pentamidine can be tolerated
c. It will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month
d. Iv pentamidine may offer protection to others aids related conditions such as kaposis sarcoma
Answer: c. It will be necessary to continue prophylactic doses of IV or aerosol pentamidine
every month
7. A client subjective data includes dysuria, urgency, and urinary frequency. What action should
the nurse implement next?
a. collect a clean catch specimen
b. palpate the suprapubic region
c. instruct to wipe from front to back
d. inquire about recent sexual activity
Answer: a. collect a clean catch specimen
8. A client tells the nurse that her biopsy results indicate that the cancer cells are well
differentiated How should the nurse respond?
a. offer the client reassurance that this information indicates that the clients cancer cells are
benign
b. explain that these tissue cells often respond more effectively to radiation than to chemotherapy
c. ask the client in the healthcare provider has giving her any information about the classification
of her cancer
d. help the client make plans to begin inmediate treatment since her cancer is likely to spread
quickly
Answer: c. ask the client in the healthcare provider has giving her any information about the
classification of her cancer
9. A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment
clients blood pressure drops from 150/90 to 80/30 Which action should the nurse take first?
a. monitor bp q45 minutes
b. lower the head of the chair and elevate feet
c. stop dialysis treatment
d. administer 5%albumin IV
Answer: c. stop dialysis treatment
10. A client with deep vein thrombosis (DVT) is receiving a continues infusion of heparin
sodium 25,000 unit in 5% dextrose injection 250ml. The prescription indicates the dosage should
be increase 900 units/hr. The nurse should program the infusion pump to deliver how many
ml/hr?
Answer: 9 mL/hr
11. The nurse is obtaining the admission history for a client with suspected peptic ulcer disease
(PUD). Which subjective data reported by the client supports this diagnosis?
a. upper mid abdominal gnawing and burning pain
b. severe abdominal cramps and diarrhea after eating spicy foods
c. marked loss of weight and appetite over the last few months
d. use of chewable and liquid antacids for indigestion
Answer: a. upper mid abdominal gnawing and burning pain
12. The nurse is providing preoperative education for a jewish client schedule to receive a
xenograft graft to promote burn healing. Which information should the nurse provide this client?
a. the xenograft is taken from nonhuman sources
b. grafting increases the risk for bacterial infection
c.as the burn heals the graft permanently attaches
d. grafts are later removed by debriding procedure
Answer: a. the xenograft is taken from nonhuman sources
13. A client who took a camping vacation two weeks ago in a country with a tropical climate
comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is
most important for the nurse to report?
a. jaundice sclera
b. intestinal cramping
c. weakness and fatigue
d. weight loss
Answer: a. jaundice sclera
14. During a home visit the nurse assesses the skin of a client with eczema who reports than an
exacerbation of symptoms has occurred during the last week. Which information is most useful
in determining the possible cause of the symptoms?
a. an old friend with eczema came for visit
b. recently received an influenza immunization
c. corticosteroid cream was applied to eczema
d. a grandson and his new dog recently visited
Answer: d. a grandson and his new dog recently visited
15. When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which
instruction should the nurse include in the dietary teaching ?
a. select a protein rich food daily
b. restrict sodium intake
c. eat high potassium foods
Answer: b. restrict sodium intake
16. A male client who is 24hr post operative for an exploratory laparotomy complains that he is
starving because he has had no real food since before surgery. Prior to advancing his diet which
intervention should the nurse implement?
a. discontinue intravenous therapy
b. Obtain a prescription for a diet change
c. Auscultate bowel sound in all four quadrants
Answer: c. Auscultate bowel sound in all four quadrants
17. A client diagnose with stable angina secondary to ischemic heart disease has a prescription
for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which
instructions if chest pain is not relieved after taking 3 NTG tables 5 min apart?
a. drive to the nearest emergency department
b. take another NTG SL tablet and lie down until angina subsides
c. call primary healthcare provider
d. call 911 pain is unrelieved and chew a tablet of aspirin 325mg
Answer: d. call 911 pain is unrelieved and chew a tablet of aspirin 325mg
18. After taking orlistat (Xenical) for one week a female client tells the home health nurse that
she is experiencing increasingly frequent oily stools and flatus. What action should the nurse
take?
a. obtain stool specimen to evaluate for occult blood and fat content
b. instruct the client to increase her intake of saturated fats over the next week
c. ask the client to describe her dietary intake history for the last several days
d. advice the client to stop taking the drug and contact the healthcare provider
Answer: c. ask the client to describe her dietary intake history for the last several days
19. Two days after an abscess of the chin was drained the client returns to the clinic with fever
chills and a maculopapular rash with pruritic. The client has taken an oral antibiotic and cleansed
the wound today with provide iodine (Betadine) solution. Which intervention should the nurse
implement first?
a. determine if the client has a history of diabetes
b. assess airway patency and oxygen saturation
c. review recent medication history and allergies
d. obtain samples for complete blood count and cultures
Answer: b. assess airway patency and oxygen saturation
20. A client experiences an ABO incompatibility reaction after multiple blood transfusions.
Which finding should the nurse report immediately to the health care provider?
a. low back pain and hypotension
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
d. arthritic joint changes and chronic pain
Answer: a. low back pain and hypotension
21. A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the intensive
care unit with hyperglycemic nonketotic syndrome (HHNS). A sliding scale protocol for an
isotonic IV solution with regular insulin is prescribed based on the results of a continuous blood
glucose monitoring device that is attached to the clients central venous catheter. When the clients
respirations become labored and his lungs sound indicate crackles what action should the nurse
take?
a. collect a specimen for a white blood cell count and cultures
b. determine the clients glycosylated hemoglobin (A1C) (POSSIBLE ANSWER)
c. administer insulin IV push until the clients fluid volume is adjusted
d. decrease infusion rate to address fluid overload
Answer: d. decrease infusion rate to address fluid overload
22. When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the
previously applied patch is intact on the clients upper back and the client denies pain. What
action should the nurse take?
a. Remove the patch and consult with the healthcare provider about the client pain resolution
b. Place the patch on the clients shoulder and leave both patches in place for 12 hours
c. Administer an oral analgesic and evaluate its effectiveness before applying a new patch
d. Apply a new patch in a different location after removing the original patch
Answer: d. Apply a new patch in a different location after removing the original patch
23. A client who had a myocardial infarction is admitted to the coronary critical care unit (CCU)
with a nitroglycerin drip infusing. The clients last blood pressure measurements was 78/36.What
action should the nurse implement?
a. obtain blood pressure q5 minutes using duranap machine
b. change the dilution of the nitroglycerin infusion
c. reduce the rate of the nitroglycerin infusion
d. begin dopamine infusion at 5mcg/kg per minute
Answer: c. reduce the rate of the nitroglycerin infusion
24. An adolescent is admitted to the hospital because of a suicide attempt with an overdose of
acetaminophen (Tylenol). Which blood values are most important for the nurse to monitor during
the first 72 hours following ingestion of this overdose?
a. BUN creatinine specific gravity
b. White blood count, hemoglobin hematocrit
c. PH, PCO2, HCO3
d. LDH OR LD, SGOT OR ALT, SGPT OR AST.
Answer: d. LDH OR LD, SGOT OR ALT, SGPT OR AST.
25. An elderly post operative female client is receiving morphine sulfate via a PCA pump. Which
assessment finding should prompt a nurse to administer the prescribed PRN medication
naloxone?
a. her respiratory rate is 7 breath/minute
b. she indicates that she feels as if she cannot get enough air to breath
c. she has intercostal retractions and bilateral wheezing is auscultated
d. her pulse oximeter is 89% on room air
Answer: a. her respiratory rate is 7 breath/minute
26. Which assessment finding indicates to the nurse that the muscarinic agent bethanechol
(Urecholine) is effective for a client diagnose with urinary retention?
a. urinary output equal to intake
b. no terminal urinary dribbling
c. denies stress incontinence
d. absence of xerostomia
Answer: a. urinary output equal to intake
27. Following involvement in a motor vehicle collision, a middle aged adult client is admitted to
the hospital with multiple facial fractures. The clients blood alcohol level is high on admission.
Which PRN prescription should be administer if the clients begins to exhibit signs and symptoms
of delirium tremens (DTs)?
a. Lorazepam (Ativan) 2mg IM
b. Chlorpromazine (thorazine) 50 mg IM
c. Prochlorperazine (Compazine) 5 mg IM
d. Hydromorphone (Dilaudid) 2 mg IM
Answer: a. Lorazepam (Ativan) 2mg IM
28. Which instructions should the nurse include in the teaching plan of a client who is taking the
diuretic spironolactone (Aldactone)?
a. call the healthcare provider f you develop gynecomastia
b. Take the medication in the morning
c. Avoid caffeine and smoking
d. Increase your consumption of bananas and oranges
Answer: b. Take the medication in the morning
29. A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When
should the nurse instruct the client to take the glucagon?
a. after meals to increase endogenous insulin secretion
b. after insulin administration to prevent hypoglycemia
c. when recognized signs of severe hypoglycemia occur
d. when unable to eat during sick days
Answer: c. when recognized signs of severe hypoglycemia occur
30. A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which
explanation should be included in preparing this client for this treatment?
a. describe radioactive iodine as a tasteless, colorless medication administered by the healthcare
provider
b. explain the need for using lead shields for 2 to 3 weeks after the treatment
c. describe the signs of goiter because this is a common side effects of radioactive iodine
d. explain that relief of the signs/ symptoms of hyperthyroidism will occur immediately
Answer: a. describe radioactive iodine as a tasteless, colorless medication administered by the
healthcare provider
31. A female client is being treated for tuberculosis with rifampin (rifadin) Which statement
indicates that further teaching is needed?
a. "I should expect my urine to turn a reddish-orange color while taking this medication."
b. "I need to take this medication at the same time every day to maintain its effectiveness."
c. "Rifampin can interfere with hormonal birth control, so I need to use a non-hormonal method
of contraception while on this medication."
d. "I will take my usual contraceptive for birth control."
Answer: d. I will take my usual contraceptive for birth control
32. A client is discharged with a prescription for warfarin ( Coumadin). What discharge
instructions should the nurse emphasize to the client?
a. take a multi vitamin supplement daily
b. use an astringent for superficial bleeding
c. avoid going barefoot especially outside
d. include large amounts of spinach in the diet
Answer: c. avoid going barefoot especially outside
33. In caring for a client with diabetes insipidus who is receiving an antidiuretic hormone
intranasally which serum lab test is most important for the nurse to monitor?
a. osmolality
b. calcium
c. platelets
d. glucose
Answer: a. osmolality
34. After administering dihydroergotamine (Migranal) 1 mg subcutaneously to a client with a
severe migraine headache the nurse should explain that relief can be expected within what time
frame?
a. 2 hours
b. 5 minutes
c. 1 hour
d. 15 minutes
Answer: d. 15 minutes
35. A client with hypertension who has been taking labetalol for two weeks, reports a five pound
(2.2 kg) weight gain. Which follow up assessment is most important for the nurse to obtain?
a. capillary refill
b. body temperature
c. muscle strength
d. breath sounds
Answer: d. breath sounds
36. A male client is receiving pilocarpine hydrochloride (Isopto Carpine) ophthalmic drops for
glaucoma. He calls the clinic and ask the nurse why he has difficulty seeing at night. What
explanation should the nurse provide?
a. The eye drops slow pupil response to accommodate for darkness
b. The drops increase the fluid in the eyes and cloud the visual field
c. The drug can cause lens to become more opaque
d. The medication causes pupils to dilate which reduces night vision
Answer: a. The eye drops slow pupil response to accommodate for darkness
37. A client who is taking and oral dose of tetracycline complains of gastrointestinal upset. What
snack should the nurse instruct the client to take with the tetracycline?
a. toasted wheat bread and jelly
b. cheese and crackers
c. cold cereal with skim milk
d. fruit flavored yogurt
Answer: a. toasted wheat bread and jelly
38. The therapeutic effect of insulin in treating type 1 diabetes mellitus is based on which
physiologic action?
a. Facilitates transport of glucose into the cell
b. Increases intracellular receptor site sensitivity
c. Stimulates function of beta cells in the pancreas
d. Delays carbohydrates digestion and absorption
Answer: a. Facilitates transport of glucose into the cell
39. The health care provider prescribe a medication for an older adult client who is complaining
of insomnia. And instructs the client to return in 2 weeks. The nurse should question which
prescription?
a. Eszoplicone (Lunesta)10 mg orally at bed time
b. Zolpidem 10 mg orally at bed time
c. Temazepan orally at bed time
d. Ramelteon orally at bedtime
Answer: a. Eszoplicone (Lunesta)10 mg orally at bed time
40. A male client reports to the nurse that he is experiencing GI distress from high dose of a
corticosteroid and is planning to stop taking the medication. In response to the clients statement
what nursing action is most important for the nurse to take?
a. Encourage the client to take medication with food to decrease GI distress
b. Advice the client that the medication should be stopped gradually rather than abruptly.
c. Review the clients dosing schedule to ensure he is taking the prescribed amount
d. Assess the client for other indication of adverse effects of corticosteroid
Answer: b. Advice the client that the medication should be stopped gradually rather than
abruptly.
41. Fifteen minutes after receiving sulfa athenozole . A male client report a burning sensation
over his abdomen chest and groin. Which intervention is most important for the nurse to
implement?
a. Auscultate lung sounds for wheezing
b. Review the clients list if drugs allergies
c. Add sulfamethinozole to clients allergies
d. Check neurological vital signs
Answer: b. Review the clients list if drugs allergies
42. Antibiotic resistant organism are a major infection control problems. To help minimize the
emergence of resistant bacteria what instruction should the nurse provide to the clients?
a. stop taking prescribed antibiotics when symptoms decrease
b. avoid using antibiotics when suffering from colds or the flu
c. ask the healthcare provider to prescribe the newest antibiotic when needed
d. request a prescription for first time vancomysin for a sore throat
Answer: b. avoid using antibiotics when suffering from colds or the flu
43. A client with symptoms of influenza that started the previous day ask the clinic nurse about
taking oseltamivir (Tamiflu) to treat the infection. Which response should the nurse provide?
a. Advise the client once symptoms occur is too late to receive an influenza vaccination
b. Refer the client to the healthcare provider at the clinic to obtain a medication prescription
c. Explain to the client that antibiotics are not useful in treating viral infections such as influenza
d. Instruct the client that over the counter medications are sufficient to manage influenza
symptoms
Answer: b. Refer the client to the healthcare provider at the clinic to obtain a medication
prescription
44. Twenty minutes after the nurse starts a secondary IV infusion of cafepime (maxipime) 2
grams using an infusion pump to deliver the dose in one hour, the client reports feeling
nauseated. What action should the nurse implement?
a. stop medication infusion and notify the healthcare provider of the adverse effect
b. increase the rate of the infusion to complete the dose of the medication more rapidly
c. continue the infusion and administer a prn antiemetic prescription
d. reassure the client that the nausea is not related to the iv infusion
Answer: c. continue the infusion and administer a prn antiemetic prescription
45. The nurse administer donepezil hydrochloride (Aricept) to a client with Alzheimers disease
as an intervention for which client problem?
a. fluid volume excess
b. disturbed though processes
c. chronic pain
d. altered breathing patterns
Answer: b. disturbed though processes
46. To prevent deep vein thrombosis following knee replacement surgery, an adult male client is
receiving enoxaparin (Lovenox) subcutaneously daily. Which laboratory finding requires
immediate action by the nurse?
a. Blood urea nitrogen (BUN) 20 mg/dL or 7.1 mmol/L (SI)
b. Hematocrit 45%
c. Serum creatinine 1.0 mg/dL or 88.4 µmol/L (SI)
d. Platelet count of 100,000/mm³ or 100 x 10⁹/L (SI)
Answer: d. Platelet count of 100,000/mm³ or 100 x 10⁹/L (SI)
