HESI EXIT RN
HESI EXIT RN V1- V7 EXAM 4 WITH NGN
2026 LATEST WITH COMPLETE QUESTIONS
AND CORRECT DETAILED ANSWERS WITH
RATIONALES GUARANTEED PASS |
GRADED A+
The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which
observation of this procedure requires the nurse to intervene with the UAP's approach?
A.
The cuff wraps around the girth of the leg.
B.
The UAP auscultates the popliteal pulse with the cuff on the lower leg.
A+ TEST BANK 1
, HESI EXIT RN
C.
The client is placed in a prone position.
D.
The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
B
Rationale: When obtaining the blood pressure in the lower extremities, the popliteal pulse is
the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse
should intervene with the UAP who has applied the cuff on the lower leg. Option A ensures
an accurate assessment, and option C provides the best access to the artery. Systolic
pressure in the popliteal artery is usually 10 to 40 mm Hg higher than in the brachial artery.
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often
awake until midnight playing and is then very difficult to awaken in the morning for school.
Which assessment data should the nurse obtain in response to the mother's concern?
A.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child is experiencing
D.
Description of the family's home environment
D
Rationale: School-age children often resist bedtime. The nurse should begin by assessing the
environment of the home to determine factors that may not be conducive to the
establishment of bedtime rituals that promote sleep. Option A often causes daytime fatigue
rather than resistance to going to sleep. Option B is unlikely to provide useful data. The nurse
cannot determine option C.
A+ TEST BANK 2
, HESI EXIT RN
The nurse identifies a potential for infection in a client with partial-thickness (second-degree)
and full-thickness (third-degree) burns. What action has the highest priority in decreasing the
client's risk of infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns
B
Rationale: Careful handwashing technique is the single most effective intervention for the
prevention of contamination to all clients. Option A reverses the hypovolemia that initially
accompanies burn trauma but is not related to decreasing the proliferation of infective
organisms. Options C and D are recommended by various burn centers as possible ways to
reduce the chance of infection. Option B is a proven technique to prevent infection.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral
IV rate by gravity has slowed, even though the venous access site is healthy. What should the
nurse do next?
A.
Apply a warm compress proximal to the site.
B.
Check for kinks in the tubing and raise the IV pole.
C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate.
B
Rationale: The nurse should first check the tubing and height of the bag on the IV pole, which
A+ TEST BANK 3
, HESI EXIT RN
are common factors that may slow the rate. Gravity infusion rates are influenced by the
height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client
blood pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate
and often responds to warmth over the vessel, but the nurse should first adjust the IV pole
height. The nurse may need to adjust the stabilizing tape on a positional needle or flush the
venous access with normal saline, but less invasive actions should be implemented first.
The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to
prevent complications of immobility. Which action should be included in this instruction?
A.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift.
A
Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around
joints. Options B, C, and D are all potentially harmful practices that place the immobile client
at risk of complications.
The nurse administered 10 mg of diazepam to the preoperative client. What steps will the
nurse take next? (Select all that apply.)
A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
A+ TEST BANK 4
HESI EXIT RN V1- V7 EXAM 4 WITH NGN
2026 LATEST WITH COMPLETE QUESTIONS
AND CORRECT DETAILED ANSWERS WITH
RATIONALES GUARANTEED PASS |
GRADED A+
The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which
observation of this procedure requires the nurse to intervene with the UAP's approach?
A.
The cuff wraps around the girth of the leg.
B.
The UAP auscultates the popliteal pulse with the cuff on the lower leg.
A+ TEST BANK 1
, HESI EXIT RN
C.
The client is placed in a prone position.
D.
The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
B
Rationale: When obtaining the blood pressure in the lower extremities, the popliteal pulse is
the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse
should intervene with the UAP who has applied the cuff on the lower leg. Option A ensures
an accurate assessment, and option C provides the best access to the artery. Systolic
pressure in the popliteal artery is usually 10 to 40 mm Hg higher than in the brachial artery.
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often
awake until midnight playing and is then very difficult to awaken in the morning for school.
Which assessment data should the nurse obtain in response to the mother's concern?
A.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child is experiencing
D.
Description of the family's home environment
D
Rationale: School-age children often resist bedtime. The nurse should begin by assessing the
environment of the home to determine factors that may not be conducive to the
establishment of bedtime rituals that promote sleep. Option A often causes daytime fatigue
rather than resistance to going to sleep. Option B is unlikely to provide useful data. The nurse
cannot determine option C.
A+ TEST BANK 2
, HESI EXIT RN
The nurse identifies a potential for infection in a client with partial-thickness (second-degree)
and full-thickness (third-degree) burns. What action has the highest priority in decreasing the
client's risk of infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns
B
Rationale: Careful handwashing technique is the single most effective intervention for the
prevention of contamination to all clients. Option A reverses the hypovolemia that initially
accompanies burn trauma but is not related to decreasing the proliferation of infective
organisms. Options C and D are recommended by various burn centers as possible ways to
reduce the chance of infection. Option B is a proven technique to prevent infection.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral
IV rate by gravity has slowed, even though the venous access site is healthy. What should the
nurse do next?
A.
Apply a warm compress proximal to the site.
B.
Check for kinks in the tubing and raise the IV pole.
C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate.
B
Rationale: The nurse should first check the tubing and height of the bag on the IV pole, which
A+ TEST BANK 3
, HESI EXIT RN
are common factors that may slow the rate. Gravity infusion rates are influenced by the
height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client
blood pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate
and often responds to warmth over the vessel, but the nurse should first adjust the IV pole
height. The nurse may need to adjust the stabilizing tape on a positional needle or flush the
venous access with normal saline, but less invasive actions should be implemented first.
The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to
prevent complications of immobility. Which action should be included in this instruction?
A.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift.
A
Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around
joints. Options B, C, and D are all potentially harmful practices that place the immobile client
at risk of complications.
The nurse administered 10 mg of diazepam to the preoperative client. What steps will the
nurse take next? (Select all that apply.)
A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
A+ TEST BANK 4
