HESI EXIT EXAM QUESTIONS AND ANSWERS
100% CORRECT!!
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? - ANSWER Stroke secondary to hemorrhage
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
hypertension.
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? - ANSWER Review with the client the need to
avoid foods that are rich in milk and cream.
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should be
avoided.
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? - ANSWER
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
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
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for
the past 12 days. Which assessment finding requires immediate follow-up? - ANSWER
Describes life without purpose
, Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that is known to
increase the risk of suicidal thinking in adolescents and young adults with major
depressive disorder. B, C and D are side effects
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? -
ANSWER d- Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client's
respiratory rate is within normal limits.
During a home visit, the nurse observed an elderly client with diabetes slip and fall.
What action should the nurse take first? - ANSWER Check the client for lacerations or
fractures
Rationale: After the client falls, the nurse should immediately assess for the possibility
of injuries and provide first aid as needed
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? - ANSWER Inform
the anesthesia care provider
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.
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? - ANSWER Listen with the bell at the same location
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.
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? - ANSWER Medicare
100% CORRECT!!
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? - ANSWER Stroke secondary to hemorrhage
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
hypertension.
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? - ANSWER Review with the client the need to
avoid foods that are rich in milk and cream.
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should be
avoided.
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? - ANSWER
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
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
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for
the past 12 days. Which assessment finding requires immediate follow-up? - ANSWER
Describes life without purpose
, Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that is known to
increase the risk of suicidal thinking in adolescents and young adults with major
depressive disorder. B, C and D are side effects
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? -
ANSWER d- Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client's
respiratory rate is within normal limits.
During a home visit, the nurse observed an elderly client with diabetes slip and fall.
What action should the nurse take first? - ANSWER Check the client for lacerations or
fractures
Rationale: After the client falls, the nurse should immediately assess for the possibility
of injuries and provide first aid as needed
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? - ANSWER Inform
the anesthesia care provider
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.
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? - ANSWER Listen with the bell at the same location
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.
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? - ANSWER Medicare
