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HESI EXIT EXAM QUESTIONS AND ANSWERS 2025 v1.
Typology: Exams
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While .assessing .a .radial .artery .catheter, .the .client .complains .of .numbness .and .pain .distal .to .the .insertion .site. .What .interventions .should .the .nurse .implement? .-- .CORRECT .ANSWER-Promptly .remove .the .arterial .catheter .from .the .radial .artery. A .client .is .admitted .with .an .epidural .hematoma .that .resulted .from .a .skateboarding .accident. .To .differentiate .the .vascular .source .of .the .intracranial .bleeding, .which .finding .should .the .nurse .monitor? .-- .CORRECT .ANSWER-Rapid .onset .of .decreased .level .of. consciousness. When .preparing .a .client .for .discharge .from .the .hospital .following .a .cystectomy .and .a .urinary .diversion .to .treat .bladder .cancer, .which .instruction .is .most .important .for .the .nurse .to .include .in .the .client's .discharge .teaching .plan? .-- .CORRECT .ANSWER-Report. any .signs .of. cloudy
. urine. output. After .repositioning .an .immobile .client, .the .nurse .observes .an .area .of .hyperemia. .To .assess .for .blanching, .what .action .should .the .nurse .take? .-- .CORRECT .ANSWER-Apply .light .pressure .over .the .area. The .nurse .enters .a .client's .room .and .observes .the .client's .wrist .restraint .secured .as .seen .in .the .picture. .What .action .should .the .nurse .take? .-- .CORRECT .ANSWER- .Reposition .the .restraint .tie .onto .the .bedframe. A .female .client .with .acute .respiratory. distress .syndrome .(ARDS) .is . chemically .paralyzed .and .sedated .while .she .is .on .as .assist-control .ventilator .using. 50%. FIO2.. Which. assessment. finding. warrants immediate .intervention .by .the .nurse? .-- .CORRECT .ANSWER-Diminished .left .lower .lobe .sounds Rationale: .Diminished .lobe .sounds .indicate .collapsed .alveoli .or .tension .pneumothorax, .which .required immediate .chest .tube .insertion .to .re-inflate .the .lung. The .development .of .atherosclerosis .is .a .process .of .sequential .events. .Arrange .the .pathophysiological .events .in .orders .of .occurrence. .(Place .the .first .event .on .top .and .the .last .on .the .bottom) .-- .CORRECT .ANSWER- Arterial .endothelium .injury .causes .inflammation Macrophages .consume .low .density .lipoprotein .(LDL), .creating .foam .cells .Foam .cells .release .growth .factors .for .smooth .muscle .cells
Smooth .muscle .grows .over .fatty .streaks .creating .fibrous .plaques .Vessel .narrowing .results .in .ischemia Following .a .motor .vehicle .collision, .an .adult .female .with .a .ruptured .spleen .and. a. blood. pressure. of. 70/44,. had. an. emergency
. splenectomy.. Twelve .hours .after .the .surgery, .her .urine .output .is. 25 .ml/hour .for .the .last .two .hours. .What .pathophysiological .reason .supports .the .nurse's .decision .to .report .this .finding .to .the .healthcare .provider? .-- .CORRECT .ANSWER-Oliguria .signals .tubular .necrosis .related .to .hypoperfusion A .nurse-manager .is .preparing .the .curricula .for .a .class .for .charge .nurses. .A .staffing .formula .based .on .what .data .ensures .quality .client .care .and .is .most .cost-effective? .-- .CORRECT .ANSWER-Skills .of .staf .f .and .client .acuity When .performing .postural .drainage .on .a .client .with .Chronic .Obstructive .Pulmonary .Disease .(COPD), .which .approach .should .the .nurse .use? .-- .CORRECT .ANSWER- .Explain .that .the .client .may .be .placed .in .five .positions A .client .presents .in .the .emergency .room .with .right-sided .facial .asymmetry. .The .nurse .asks .the .client .to .perform .a .series .of .movements .that .require .use .of .the .facial .muscles. .What .symptoms .suggest .that .the .client .has .most .likely .experience .a .Bell's .palsy .rather .than .a .stroke? .-- .CORRECT .ANSWER-Inability .to .close .the .affected .eye, .raise .brow, .or .smile The .nurse .is .teaching .a .client .how .to .perform .colostomy .irrigations. .When .observing .the .client's .return .demonstration, .which .action .indicated .that .the .client .understood .the .teaching? .-- .CORRECT .ANSWER-Keeps .the .irrigating .container .less .than. 18 .inches .above .the .stoma The .nurse .should .teach .the .client .to .observe .which .precaution .while .taking .dronedarone? .-- .CORRECT .ANSWER-Avoid .grapefruits .and .its .juice A .client .who .sustained .a .head .injury .following .an .automobile .collision .is .admitted .to .the .hospital. .The .nurse .include .the .client's .risk .for .developing .increased .intracranial .pressure .(ICP) .in .the .plan .of .care. .Which .signs .indicate .to .the .nurse .that .ICP .has .increased? .-- .CORRECT .ANSWER- .Increased .Glasgow .coma .scale .score. Nuchal .rigidity .and .papilledema. .Confusion .and .papilledema .Periorbital .ecchymosis. Rationale: .papilledema .is .always .an .indicator .of .increased .ICP, .and .confusion .is .usually .the .first .sign .of
The .nurse .is .caring .for .a .client .receiving .continuous .IV .fluids .through .a
. single .lumen .central .venous .catheter .(CVC). .Based .on .the .CVC .care .bundle, .which .action .should .be .completed .daily .to .reduce .the risk .for .infection? .-- .CORRECT .ANSWER-Confirm .the .necessity .for .continued .use .of .the .CVC. During .an .annual .physical .examination, .an .older .woman's .fasting .blood .sugar .(FBS) .is .determined .to .be. 140 .mg/dl .or .7.8 .mmol/L .(SI). .Which .additional .finding .obtained .during .a .follow-up .visit. 2 .weeks .later .is .most .indicative .that .the .client .has .diabetes .mellitus .(DM)? .-- .CORRECT .ANSWER- .Repeated .fasting .blood .sugar .(FBS) .is. 132 .mg/dl .or .7. .mmol/L .(SI). A .client .who .was .admitted .yesterday .with .severe .dehydration .is . complaining .of .pain .a. 24 .gauge .IV .with .normal .saline .is .infusing .at .a .rate .of. 150 .ml/hour. .Which .intervention .should .the .nurse .implement .first? .-- .CORRECT .ANSWER-Stop .the .normal .saline .infusion. An .elderly .female .is .admitted .because .of .a .change .in .her .level .of .sensorium. .During .the .evening .shift, .the .client .attempts .to .get .out .bed .and .falls, .breaking .her .left .hip. .Buck's .skin .traction .is .applied .to .the .left .leg .while .waiting .for .surgery. .Which .intervention .is .most .important .for .the .nurse .to .include .in .this .client's .plan .care? .-- .CORRECT .ANSWER-Ensure .proper .alignment .of .the .leg .in .traction. A .client .who .had .a .right .hip .replacement. 3 .day .ago .is .pale .has .diminished .breath .sound .over .the .left .lower .lung .fields, .a .temperature .of .100.2. F, .and .an. oxygen. saturation. rate. of .90%.. The .client. is .scheduled . to .be .transferred .to .a .skilled .nursing .facility .(SNF) .tomorrow .for .rehabilitative .critical .pathway. .Based. on. the. client's. symptoms,. what . recommendation. should. the. nurse .give. the. healthcare. provider?. -- . CORRECT. ANSWER-Reassess. readiness. for .SNF .transfer. A .client .who .is .newly .diagnosed .with .type. 2 .diabetes .mellitus .(DM) .receives .a .prescription .for .metformin .(Glucophage). 500 .mg .PO .twice .daily. .What .information .should .the .nurse .include .in .this .client's .teaching .plan? .(Select. all .that .apply.) .-- .CORRECT .ANSWER-Recognize .signs .and .symptoms .of .hypoglycemia. Report .persist .polyuria .to. the. healthcare .provider. .Take .Glucophage .with .the .morning .and .evening .meal. The .nurse .is .developing .an .educational .program .for .older .clients .who .are .being .discharged .with .new .antihypertensive .medications. .The .nurse .should .ensure .that .the .educational .materials .include .which
characteristics? .Select .all .that .apply .-- .CORRECT .ANSWER-Written .at .a .twelfth
Contains .a .list .with .definitions .of .unfamiliar .terms .Uses .common .words .with .few .Syllables Printed .using .a. 12 .point .type .font Uses .pictures .to .help .illustrate .complex .ideas Rationale: .During .the .aging .process .older .clients .often .experience .sensory .or .cognitive .changes, .such .as decreased .visual .or .hearing .acuity, .slower .thought .or .reasoning .processes, .and .shorter .attention .span. Materials .for .this .age .group .should .include .at .least .of .terms, .such .as .a .medical .terminology .that .incline may .not .know .and .use .common .words .that .expresses .information .clearly .and .simply. .Simple, .attractive pictures .help .hold .the .learner's .attention. .The .reading .level .of .material .should .be .at .the .4th .to .5th .grade level. .Materials .should .be .printed .using .large .font .(18-point .or .higher), .not .the .standard. 12 - point .font. During .the .admission .assessment, .the .nurse .auscultates .heart .sounds .for .a. client .with .no .history .of .cardiovascular .disease. .Where .should .the .nurse .listen .when .assessing .the .client's .point .of .maximal impulse .(PMI) .(Click .the .chosen .location. .To .change, .click .on .a .new .location) -- .CORRECT .ANSWER-Left .Fourth .Intercostal .Space An .older .male .adult .resident .of .long-term .care .facility .is .hospitalized .for .a .cardiac .catheterization .that .occurred .yesterday. .Since .the .procedure .was .conducted, .the .client .has .become .increasingly .disoriented. .The .night .shift .nurse .reports .that .he .attempted .to .remove .the .sandbag .from .his .femoral .artery .multiple .times .during .the .night. .What .actions .should .the .nurse .take? .(Select .all .that .apply.) .-- .CORRECT .ANSWER-Notify .the .healthcare .provider .of .the .client's .change .in .mental .status. Include .q2 .hour's .reorientation .in .the .client's .plan .of .care. An .older .male .comes .to .the .clinic .with .a .family .member. .When .the .nurse .attempts .to .take .the .client's .health .history, .he .does .not .respond .to .questions .in .a .clear .manner. .What .action .should .the .nurse implement .first? .-- .CORRECT .ANSWER-Assess .the .surroundings .for .noise .and. distractions. The .nurse .caring .for .a .client .with .acute .renal .fluid .(ARF) .has .noted .that .the .client .has .voided. 800 .ml .of .urine .in. 4 .hours. .Based .on .this .assessment, .what .should .the .nurse .anticipate .that .client .will .need? .-- .CORRECT .ANSWER-Large .amounts .of .fluid .and .electrolyte .replacement.
Which .intervention .should .the .nurse .include .in .the .plan .of .care .for .a .child .with .tetanus? .-
disease .(COPD) .and .diabetes .mellitus. .While .completing .the .pulmonary .assessment, .the .nurse .hears .wheezing .and .poor .air .movement .bilaterally. .Which .actions .should .the .nurse .implement? .(Select .all .that .apply.) .-- .CORRECT .ANSWER-Administer .PRN .nebulizer .treatment. Obtain. 12 .lead .electrocardiogram. .Monitor .continuous .oxygen .saturation. The .nurse .caring .for .a. 3 - month-old .boy .one .day .after .a .pylorotomy .notices .that .the .infant .is .restless, .is .exhibiting .facial .grimaces, .and .is .drawing .his .knees .to .his .chest. .What .action .should .the .nurse .take? .-- .CORRECT. ANSWER-Administer .a .prescribed .analgesia .for .pain. A. 4 - year-old .with .acute .lymphocytic .leukemia .(ALL) .is .receiving .a .chemotherapy .(CT) .protocol .that .includes .methotrexate .(Mexate, .Trexal, .MIX), .an .antimetabolite. .Which .information .should .the .nurse provide .the .parents .about .caring .for .their .child? .-- .CORRECT .ANSWER- Use .sunblock .or .protective .clothing .when .outdoors. Two .days .after .admission .a .male .client .remembers .that .he .is .allergic .to .eggs, .and .informs .the .nurse .of .the .allergy. .Which .actions .should .the .nurse .implement? .(Select .all .that .apply) .-- .CORRECT .ANSWER-Notify .the .food .services .department .of .the .allergy. .Enter .the .allergy .information .in .the .client's .record. Add .egg .allergy .to .the .client's .allergy .arm .band. The .rapid .response .team's .detects .return .of .spontaneous .circulation .(ROSC) .after. 2 .min .of .continuous .chest .compressions. .The .client .has .a .weak, .fast .pulse .and .no .respiratory .effort, .so .the .healthcare provider. performs. a. successful. oral,. intubation.. What .action. should. the .nurse. implement?. -- .CORRECT. ANSWER-Perform. bilateral .chest .auscultation. After .administering .an .antipyretic .medication. .Which .intervention .should .the .nurse .implement?. -- .CORRECT. ANSWER-Encouraging. liberal .fluid .intake A .client .with .hyperthyroidism .is .being .treated .with .radioactive .iodine .(I- 131). .Which .explanation .should .be .included .in .preparing .this .client .for .this .treatment? .-- .CORRECT .ANSWER-Describe .radioactive .iodine .as .a .tasteless, .colorless .medication .administered .by .the .healthcare .provider After .a .colon .resection .for .colon .cancer, .a .male .client .is .moaning .while .being .transferred .to .the .Postanesthesia .Care .Unit .(PACU). .Which .intervention .should .the .nurse .implement .first? .-- .CORRECT .ANSWER-
.Determine .client's .pulse, .blood .pressure, .and .respirations
.this .data, .which .nursing .assessment .is .most .important .following .the
. procedure? .-- .CORRECT .ANSWER-Observe .aspiration .site.
Assess .body .temperature .Monitor .skin .elasticity .Measure .urinary .output An. 18 - year-old .female .client .is .seen .at .the .health .department .for .treatment .of .condylomata .acuminate .(perineal .warts) .caused .by .the .human .papillomavirus .(HPV). .Which .intervention .should .the .nurse implement? .-- .CORRECT .ANSWER-Reinforce .the .importance .of .annual .papanicolaou .(Pap) .smears. A .client .admitted .to .the .psychiatric .unit .diagnosed .with .major .depression .wants .to .sleep .during .the .day, .refuses .to .take .a .bath, .and .refuses .to .eat. .Which .nursing .intervention .should .the .nurse .implement .first? .-- .CORRECT .ANSWER-Establish .a .structured .routine .for .the .client .to .follow. A .client .with .history .of .bilateral .adrenalectomy .is .admitted .with .a .week, .irregular .pulse, .and .hypotension. .Which .assessment .finding .warrants .immediate .intervention .by .the .nurse? .-- .CORRECT .ANSWER- Ventricular .arrhythmias. Rationale: .adrenal .crisis, .a .potential .complication .of .bilateral .adrenalectomy, .results .in .the .loss .of mineralocorticoids .and .sodium .excretions .that .is .characterized .by .hyponatremia, .hyperkalemia, dehydration, .and .hypotension. .Ventricular .arrhythmias .are .life .threatening .and .required .immediate intervention .to .correct .critical .potassium .levels. A .resident .of .a .long-term .care .facility, .who .has .moderate .dementia, .is .having .difficulty .eating .in .the .dining .room. .The .client .becomes .frustrated .when .dropping .utensils .on .the .floor .and .then .refuses .to .eat. .What .action .should .the .nurse .implement? .-- .CORRECT .ANSWER- Encourage .the .client .to .eat .finger .foods. A .client .is .receiving .mesalamine. 800 .mg .PO .TID. .Which .assessment .is .most. important .for .the .nurse .to .perform .to .assess .the .effectiveness .of .the .medication? .-- .CORRECT .ANSWER-Bowel .patterns Rationale: .the .client .should .be .assessed .for .a .change .in .bowel .patterns .to .evaluate .the .effectiveness .of this .medication .because .Mesalamine .is .used .to .treat .ulcerative .colitis .(a .condition .which .causes .swelling
ulcerative .colitis .symptoms. .Mesalamine .is .in .a .class .of .medications .called .anti- .inflammatory .agents. .It works .by .stopping .the .body .from .producing .a .certain .substance .that .may .cause .inflammation. While .in .the .medical .records .department, .the .nurse .observes .several .old .medical .records .with .names .visible .in .waste .container. .What .action .should .the .nurse .implement? .-- .CORRECT .ANSWER-Contact .the .medical .records .department .supervisor. A. 16 - year-old .adolescent .with .meningococcal .meningitis .is .receiving .a .continuous .IV .infusion .of .penicillin .G, .which .is .prescribed .as. 20 .million .units .in .a .total .volume .of. 2 .liters .of .normal .saline .every. 24 .hr. .The .pharmacy .delivers. 10 .million .units/ .liters .of .normal .saline. .How .many .ml/hr .should .the .nurse .program .the .infusion .pump? .(Enter .numeric .value .only. .If .rounding .is .required, .round .to .the .nearest .whole .number.) .-- .CORRECT .ANSWER-Answer. 83 Rationale:. 1000. ml12hr. Xml -------1hr. 1000/12 .= .83.33 .= .83. While .visiting .a .female .client .who .has .heart .failure .(HF) .and .osteoarthritis, .the .home .health .nurse .determines .that .the .client .is .having .more .difficulty .getting .in .and .out .of .the .bed .than .she .did .previously. .Which .action .should .the .nurse .implement .first? CORRECT .ANSWER-Submit .a .referral .for .an .evaluation .by .a .physical .therapist. A .client .has .an .intravenous .fluid .infusing .in .the .right .forearm. .To .determine .the .client's .distal .pulse .ratemost .accurately, .which .action .should .the .nurse .implement? CORRECT .ANSWER-Palpate .at .the .radial .pulse .site .with .the .pads .of .two .or .three .fingers. A .child .is .admitted .to .the .pediatric .unit .diagnosed .with .sickle .cell .crisis. .When .the .nurse .walks .into .the .room, .the .unlicensed .assistive .personnel .(UAP) .is .encouraging .the .child .to .stay .in .bed .in .the .supine position.. Which .action .should .the .nurse .implement?CORRECT. ANSWER- Reposition the .client .with .the .head .of .the .bed .elevated. A .preschool-aged .boy .is .admitted .to .the .pediatric .unit .following .successful .resuscitation .from .a .near- .drowning .incident. .While .providing .care .to .child, .the .nurse .begins .talking .with .his .preadolescent .brother .who .rescued .the .child .from .the .swimming .pool .and .initiated
.resuscitation. .The .nurse .notices .the .older
.daily. .Report .serum .albumin .and .globulin. levels.. Provide. diet
. low. in
phosphorous.