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HESI RN Exit Exam
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Showing 20 questions, Sign in for moreA 24-year-old female client presents to the emergency department (ED) with reports of abdominal pain. Client reports that she was vacuuming her home approximately 1 hour prior to arrival when she had a sudden onset of abdominal pain. She also reports nausea and vomiting. Has a prior medical history of anxiety and constipation. Informed has regular bowel movements every day. Her last bowel movement was this morning. The stool was soft and formed. There are no known diagnosed allergies. Her last menstrual period was reported to be 1 week ago. She is not currently sexually active. Her last partner was two years ago.
0930
The client arrives to the emergency department (ED) with reports of abdominal pain, nausea, and vomiting.
Assessment
Neurological: Alert and oriented. Reports she feels anxious.
Cardiovascular: Tachycardic. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
Respiratory: Tachypneic and shallow breathing. Clear breath sounds bilaterally.
Gastrointestinal: Severe abdominal pain in right lower quadrant. Reports nausea, vomiting small amounts of green bile. Genitourinary: Within normal limits (WNL). Denies burning with urination.
Musculoskeletal: WNL
Pain: Severe abdominal pain in right lower quadrant to the right of the umbilicus. Started approximately 1 hour ago.
0930
Vital signs
- Temperature: 100.8° F (38.2" C)
- Heart rate: 121 beats/minute
- Respirations: 28 breaths/minute
- Blood pressure: 115/76 mm Hg
- Oxygen saturation: 959% on room air
- Pain: 9 on a 0 to 10 scale
Patient Data
Select the 4 assessment findings that require immediate follow up.
A 24-year-old female client presents to the emergency department (ED) with reports of abdominal pain. Client reports that she was vacuuming her home approximately 1 hour prior to arrival when she had a sudden onset of abdominal pain. She also reports nausea and vomiting. Has a prior medical history of anxiety and constipation. Informed has regular bowel movements every day. Her last bowel movement was this morning. The stool was soft and formed. There are no known diagnosed allergies. Her last menstrual period was reported to be 1 week ago. She is not currently sexually active. Her last partner was two years ago.
0930
The client arrives to the emergency department (ED) with reports of abdominal pain, nausea, and vomiting.
Assessment
Neurological: Alert and oriented. Reports she feels anxious.
Cardiovascular: Tachycardic. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
Respiratory: Tachypneic and shallow breathing. Clear breath sounds bilaterally.
Gastrointestinal: Severe abdominal pain in right lower quadrant. Reports nausea, vomiting small amounts of green bile. Genitourinary: Within normal limits (WNL). Denies burning with urination.
Musculoskeletal: WNL
Pain: Severe abdominal pain in right lower quadrant to the right of the umbilicus. Started approximately 1 hour ago.
0930
Vital signs
- Temperature: 100.8° F (38.2" C)
- Heart rate: 121 beats/minute
- Respirations: 28 breaths/minute
- Blood pressure: 115/76 mm Hg
- Oxygen saturation: 959% on room air
- Pain: 9 on a 0 to 10 scale
Day 1, 1000
Complete blood count (CBC), comprehensive metabolic panel (CMP), urine pregnancy test
Place peripheral IV catheter
Lactated Ringer's 1 liter bolus
Ondansetron 4 mg IV STAT
Morphine 4 mg IV STAT.
Computed tomography (CT) scan of abdomen
Day 1, 1130
Admit client to hospital
1100
Computed tomography (CT) scan of abdomen: Dilated appendix 7 mm in diameter and fat stranding noted.
The healthcare provider places orders to determine the cause of client symptoms.
Use the chart to indicate if the listed symptom or finding is consistent with gastroenteritis, appendicitis, or ectopic pregnancy.
Each row must have at least one, but may have more than one, response option selected.
Explanation
Fever is a common symptom that can be present in gastroenteritis, appendicitis, and, less commonly, ectopic pregnancy. Tachycardia may occur in all three conditions but is more commonly associated with ectopic pregnancy, especially if there is internal bleeding. Nausea and vomiting are symptoms that can be seen in gastroenteritis and appendicitis, and occasionally in ectopic pregnancy. Diarrhea is most commonly associated with gastroenteritis.
A 24-year-old female client presents to the emergency department (ED) with reports of abdominal pain. Client reports that she was vacuuming her home approximately 1 hour prior to arrival when she had a sudden onset of abdominal pain. She also reports nausea and vomiting. Has a prior medical history of anxiety and constipation. Informed has regular bowel movements every day. Her last bowel movement was this morning. The stool was soft and formed. There are no known diagnosed allergies. Her last menstrual period was reported to be 1 week ago. She is not currently sexually active. Her last partner was two years ago.
0930
The client arrives to the emergency department (ED) with reports of abdominal pain, nausea, and vomiting.
Assessment
Neurological: Alert and oriented. Reports she feels anxious.
Cardiovascular: Tachycardic. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
Respiratory: Tachypneic and shallow breathing. Clear breath sounds bilaterally.
Gastrointestinal: Severe abdominal pain in right lower quadrant. Reports nausea, vomiting small amounts of green bile. Genitourinary: Within normal limits (WNL). Denies burning with urination.
Musculoskeletal: WNL
Pain: Severe abdominal pain in right lower quadrant to the right of the umbilicus. Started approximately 1 hour ago.
0930
Vital signs
- Temperature: 100.8° F (38.2" C)
- Heart rate: 121 beats/minute
- Respirations: 28 breaths/minute
- Blood pressure: 115/76 mm Hg
- Oxygen saturation: 959% on room air
- Pain: 9 on a 0 to 10 scale
Day 1, 1000
Complete blood count (CBC), comprehensive metabolic panel (CMP), urine pregnancy test
Place peripheral IV catheter
Lactated Ringer's 1 liter bolus
Ondansetron 4 mg IV STAT
Morphine 4 mg IV STAT.
Computed tomography (CT) scan of abdomen
Day 1, 1130
Admit client to hospital
1100
Computed tomography (CT) scan of abdomen: Dilated appendix 7 mm in diameter and fat stranding noted.
Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse recognizes that the client has
Explanation
Appendicitis is the most likely diagnosis, given the right lower quadrant (RLQ) pain, fever, nausea, vomiting, and CT findings of a dilated appendix with fat stranding. CT scan results confirming appendix dilation and fat stranding indicate inflammation, which is characteristic of appendicitis. WBC count is often elevated in appendicitis due to the inflammatory response and potential infection. Gastroenteritis is unlikely since there is no history of diarrhea or recent illness, and pneumonia is not relevant given the primary abdominal symptoms.
A 24-year-old female client presents to the emergency department (ED) with reports of abdominal pain. Client reports that she was vacuuming her home approximately 1 hour prior to arrival when she had a sudden onset of abdominal pain. She also reports nausea and vomiting. Has a prior medical history of anxiety and constipation. Informed has regular bowel movements every day. Her last bowel movement was this morning. The stool was soft and formed. There are no known diagnosed allergies. Her last menstrual period was reported to be 1 week ago. She is not currently sexually active. Her last partner was two years ago.
0930
The client arrives to the emergency department (ED) with reports of abdominal pain, nausea, and vomiting.
Assessment
Neurological: Alert and oriented. Reports she feels anxious.
Cardiovascular: Tachycardic. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
Respiratory: Tachypneic and shallow breathing. Clear breath sounds bilaterally.
Gastrointestinal: Severe abdominal pain in right lower quadrant. Reports nausea, vomiting small amounts of green bile. Genitourinary: Within normal limits (WNL). Denies burning with urination.
Musculoskeletal: WNL
Pain: Severe abdominal pain in right lower quadrant to the right of the umbilicus. Started approximately 1 hour ago.
0930
Vital signs
- Temperature: 100.8° F (38.2" C)
- Heart rate: 121 beats/minute
- Respirations: 28 breaths/minute
- Blood pressure: 115/76 mm Hg
- Oxygen saturation: 959% on room air
- Pain: 9 on a 0 to 10 scale
Day 1, 1000
Complete blood count (CBC), comprehensive metabolic panel (CMP), urine pregnancy test
Place peripheral IV catheter
Lactated Ringer's 1 liter bolus
Ondansetron 4 mg IV STAT
Morphine 4 mg IV STAT.
Computed tomography (CT) scan of abdomen
Day 1, 1130
Admit client to hospital
1100
Computed tomography (CT) scan of abdomen: Dilated appendix 7 mm in diameter and fat stranding noted.
The nurse is stabilizing the client and preparing her for surgery.
What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.
A 24-year-old female client presents to the emergency department (ED) with reports of abdominal pain. Client reports that she was vacuuming her home approximately 1 hour prior to arrival when she had a sudden onset of abdominal pain. She also reports nausea and vomiting. Has a prior medical history of anxiety and constipation. Informed has regular bowel movements every day. Her last bowel movement was this morning. The stool was soft and formed. There are no known diagnosed allergies. Her last menstrual period was reported to be 1 week ago. She is not currently sexually active. Her last partner was 2 years ago.
0930
The client arrives to the emergency department (ED) with reports of abdominal pain, nausea, and vomiting.
Assessment
Neurological: Alert and oriented. Reports she feels anxious.
Cardiovascular: Tachycardic. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
Respiratory: Tachypneic and shallow breathing. Clear breath sounds bilaterally.
Gastrointestinal: Severe abdominal pain in right lower quadrant. Reports nausea, vomiting small amounts of green bile. Genitourinary: Within normal limits (WNL). Denies burning with urination.
Musculoskeletal: WNL
Pain: Severe abdominal pain in right lower quadrant to the right of the umbilicus. Started approximately 1 hour ago.
0930
Vital signs
- Temperature: 100.8° F (38.2" C)
- Heart rate: 121 beats/minute
- Respirations: 28 breaths/minute
- Blood pressure: 115/76 mm Hg
- Oxygen saturation: 959% on room air
- Pain: 9 on a 0 to 10 scale
Day 1, 1000
Complete blood count (CBC), comprehensive metabolic panel (CMP), urine pregnancy test
Place peripheral IV catheter
Lactated Ringer's 1 liter bolus
Ondansetron 4 mg IV STAT
Morphine 4 mg IV STAT.
Computed tomography (CT) scan of abdomen
Day 1, 1130
Admit client to hospital
1100
Computed tomography (CT) scan of abdomen: Dilated appendix 7 mm in diameter and fat stranding noted.
The nurse is caring for the client the morning after her surgery.
Click to select the 5 most important nursing interventions for postoperative client care.
A 24-year-old female client presents to the emergency department (ED) with reports of abdominal pain. Client reports that she was vacuuming her home approximately 1 hour prior to arrival when she had a sudden onset of abdominal pain. She also reports nausea and vomiting. Has a prior medical history of anxiety and constipation. Informed has regular bowel movements every day. Her last bowel movement was this morning. The stool was soft and formed. There are no known diagnosed allergies. Her last menstrual period was reported to be 1 week ago. She is not currently sexually active. Her last partner was 2 years ago.
0930
The client arrives to the emergency department (ED) with reports of abdominal pain, nausea, and vomiting.
Assessment
Neurological: Alert and oriented. Reports she feels anxious.
Cardiovascular: Tachycardic. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
Respiratory: Tachypneic and shallow breathing. Clear breath sounds bilaterally.
Gastrointestinal: Severe abdominal pain in right lower quadrant. Reports nausea, vomiting small amounts of green bile. Genitourinary: Within normal limits (WNL). Denies burning with urination.
Musculoskeletal: WNL
Pain: Severe abdominal pain in right lower quadrant to the right of the umbilicus. Started approximately 1 hour ago.
0930
Vital signs
- Temperature: 100.8° F (38.2" C)
- Heart rate: 121 beats/minute
- Respirations: 28 breaths/minute
- Blood pressure: 115/76 mm Hg
- Oxygen saturation: 959% on room air
- Pain: 9 on a 0 to 10 scale
Day 1, 1000
Complete blood count (CBC), comprehensive metabolic panel (CMP), urine pregnancy test
Place peripheral IV catheter
Lactated Ringer's 1 liter bolus
Ondansetron 4 mg IV STAT
Morphine 4 mg IV STAT.
Computed tomography (CT) scan of abdomen
Day 1, 1130
Admit client to hospital
1100
Computed tomography (CT) scan of abdomen: Dilated appendix 7 mm in diameter and fat stranding noted.
The client has recovered from surgery and is ready to be discharged.
Highlight findings that indicate the client is stable and ready to be discharged.
The client returned from appendectomy surgery last night at approximately 2100. The client was admitted for observation due to a delay in waking from anesthesia. The client is currently resting in bed. The incision dressing is dry and intact, and no bleeding is noted. The client tolerated clear liquids post recovery and has advanced to a soft diet. The client ambulated around the unit this morning and tolerated activity well. Bowel sounds are present in all 4 quadrants, and per client report, she has passed flatus. Pain is tolerated with analgesia PO.
Explanation
Dressing is dry and intact with no signs of bleeding or infection: A clean, dry, intact incision with no drainage, erythema, or swelling indicates proper wound healing and a low risk of post-operative infection. Post-appendectomy clients must be assessed for potential wound complications like dehiscence (wound reopening) or infection (redness, purulent drainage, warmth). Since no abnormalities are reported, the client’s surgical site is healing well, supporting discharge readiness.
Successfully advanced from clear liquids to a soft diet without issues: After surgery, clients are started on a clear liquid diet to assess tolerance. If no nausea, vomiting, or bloating occurs, they progress to a soft diet before discharge. Tolerance to oral intake ensures the gastrointestinal (GI) tract is functioning and that the client can maintain adequate nutrition and hydration at home.
Client has ambulated around the unit and tolerated activity well: Early ambulation after surgery is crucial in preventing complications such as deep vein thrombosis (DVT), pulmonary embolism (PE), and postoperative ileus (temporary bowel paralysis). Tolerating ambulation means the client can move independently, reducing the risk of complications related to prolonged bed rest, such as muscle deconditioning and respiratory complications.
Bowel sounds are present in all four quadrants, and the client has passed flatus: The presence of bowel sounds in all quadrants and the passage of flatus (gas) are key indicators that the intestines are resuming normal function after surgery.
Postoperative ileus, a common complication after abdominal surgery, can delay discharge if present. The return of bowel function suggests that the GI system is recovering appropriately, allowing the client to eat and digest food normally.
Pain is well-controlled with oral analgesia: Pain control is an essential criterion for discharge. The client must be able to manage discomfort at home with prescribed oral medications. The ability to tolerate oral analgesics (instead of IV pain management) means the client is independent of hospital-based interventions, making home recovery feasible.
When providing client care, the nurse identifies a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence-based. When gathering evidence, which consideration is most important?
The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider (HCP), the nurse receives several prescriptions for the client, including a STAT computerized tomography (CT) scan of the head. Which intervention should the nurse perform in the immediate management of the client?
A client with a permanent pacemaker has no pulse or spontaneous respirations and the monitor is displaying a ventricular fibrillation rhythm. Resuscitation is in progress and the nurse is preparing to defibrillate the client with 200 joules of unsynchronized defibrillation. Which intervention is most important for the nurse to implement?
The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?
The nurse observes an unlicensed assistive personal (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?
The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?
The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?
A client with pancreatitis reports severe epigastric pain, so the nurse administers a prescribed narcotic analgesic Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?
1200
Vital signs
- Temperature: 98.6° F (37° C)
- orally Heart rate: 84 beats/minute
- Respirations: 15 breaths/minute
- Blood pressure: 120/67 mm Hg
- Pain: 4 on a 0 to 10 scale
1600
Vital signs
- Temperature: 98.6° F (37° C)
- orally Heart rate: 93 beats/minute
- Respirations: 16 breaths/minute
- Blood pressure: 113/64 mm Hg
- Pain: 5 on a 0 to 10 scale
Vital signs
- Temperature: 97° F (36.1° C)
- orally Heart rate: 104 beats/minute
- Respirations: 22 breaths/minute
- Blood pressure: 100/57 mm Hg
- Pain: 10 on a 0 to 10 scale
The client is a 19-year-old male who was struck by a vehicle while jogging. The client went to the operating room (OR) for an exploratory laparotomy and a small liver laceration was repaired. The client was then admitted to the surgical floor.
1200
The wound is 3.9" (10 cm) and approximated with sutures. The dressing is clean and dry.
1600
Scant bloody drainage noted on the surgical dressing.
2000
Noted surgical dressing was off the wound. The sutures on the bottom of the wound were open approximately 2 inches (5 cm) and intestinal tissue was noted protruding from the wound.
Patient Data
Which should the nurse immediately do? Select all that apply.
The client is a 24-year-old female who fell while horseback riding. Witnesses told the paramedics who treated her in the field that the horse may have stepped on her at least once after she fell. She has a large hematoma in the abdominal area, and her abdomen is distended. She is currently intubated with a 7.5 mm endotracheal tube and has two 18 gauge peripheral intravenous (PIV) lines. The client will go to the operating room for an exploratory laparotomy.
1600
Admitted client. Vital signs: heart rate 128 beats/minute, rhythm sinus tachycardia, respiratory rate 14 breaths/minute, oxygen saturation 100% on 40% fraction of inspired oxygen, temperature 96.9° F (36.1° C), blood pressure 90/79 mm Hg. Pulse pressure calculated to be less than 40 mm Hg. The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a peripheral intravenous line in the right forearm and one in the left hand. The client also has a right subclavian central venous catheter that is infusing propofol and intravenous fluids.
1800
|
Laboratory Test |
Result |
Reference Range |
|
Hemoglobin |
9.3 g/dL (93 g/L) |
12 to 16 g/dL (120 to 160 g/L) |
|
Hematocrit |
30% (0.30 volume fraction) |
37% to 47% (0.37 to 0.47 volume fraction) |
|
Prothrombin time |
11.5 seconds |
11 to 12.5 seconds |
|
Partial thromboplastin time |
64 seconds |
60 to 70 seconds |
|
Blood type |
B+ |
|
1600
Admit to the trauma intensive care unit Connect to the cardiorespiratory monitor STAT chest x-ray post central line and ETT placement
Vital signs every hour
Ventilator settings: respiratory rate 14 breaths/minute, tidal volume 400 mL
Propofol 0.03 mg/kg/min IV infusion
0.9% sodium chloride with 59% dextrose and
20 mEq potassium chloride IV infusion at 100
1200
Computerized tomography (CT) scan of the abdomen: Lacerations to the liver and spleen, blood noted in the peritoneum.
1610
Chest x-ray: Endotracheal tube and central line in place.
Review H and P and nurses’ notes.
Click to highlight which assessment findings should the nurse attend to right away?
Admitted client. Vital signs: heart rate 128 beats/minute, rhythm sinus tachycardia, respiratory rate 14 breaths/minute, oxygen saturation 100% on 40% fraction of inspired oxygen, temperature 96.9° F (36.1° C), blood pressure 90/79 mm Hg. Pulse pressure calculated to be less than 40 mm Hg. The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a peripheral intravenous line in the right forearm and one in the left hand. The client also has a right subclavian central venous catheter that is infusing propofol and intravenous fluids.
Explanation
Heart Rate: 128 beats/min (Sinus Tachycardia): Sinus tachycardia can be a compensatory response to hypovolemia, internal bleeding, or pain. Given the liver and spleen lacerations identified on the CT scan and blood in the peritoneum, tachycardia may indicate ongoing hemorrhage or hypoperfusion.
Blood Pressure: 90/79 mmHg (Narrow Pulse Pressure): A pulse pressure of less than 40 mmHg suggests inadequate perfusion and possible hemorrhagic shock. The systolic blood pressure (90 mmHg) is at the lower limit of normal, but the diastolic pressure (79 mmHg) is elevated, which can indicate compensatory vasoconstriction due to hypovolemia. Immediate fluid resuscitation or blood transfusion may be required to prevent worsening shock.
Temperature: 96.9°F (36.1°C): Trauma clients, especially those with hemorrhage, are at risk for trauma triad of death (hypothermia, acidosis, coagulopathy) due to massive fluid shifts and blood loss. Even mild hypothermia can impair coagulation and worsen bleeding, requiring active warming measures (e.g., warm IV fluids, heated blankets).
Abdominal Ecchymosis and Hematoma: Significant bruising around the surgical dressing suggests ongoing internal bleeding or vascular injury.
Close monitoring is needed to assess for expanding hematoma, increased abdominal distension, or hemodynamic instability.
A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with possible methicillin- resistant Staphylococcus aureus (MRSA) infection. Which interventions should the nurse include in the plan of care? Select all that apply.
The nurse is preparing to administer a formula feeding by nasogastric tube (NGT) to a 2-month-old. Which intervention should the nurse implement?
While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?
The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?
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