,
,Question 1
The nurse is performing preoperative care for a client undergoing an open reduction and
internal fixation (ORIF) of a fractured right tibia. Before the procedure, which action should the
nurse prioritize?
A) Administer preoperative antibiotics
B) Verify the client's signed consent
C) Apply sequential compression devices
D) Start the IV infusion as prescribed
Answer: B) Verify the client's signed consent
Rationale: Before any surgical procedure, verifying that the client has signed the informed
consent form is a legal and ethical priority. Anesthesia or surgery cannot proceed without valid
informed consent. Ensuring that the consent is signed and witnessed protects the patient's
rights and the healthcare facility from liability.
Question 2
A client receives a prescription for acetaminophen 1,000 mg by mouth every 8 hours as needed
for pain. The bottle is labeled "Acetaminophen for Oral Suspension, USP 500 mg per 15 mL."
How many tablespoons should the nurse instruct the client to take with each dose?
Answer: 2 tablespoons
Rationale: Calculation: (1000 mg desired dose ÷ 500 mg available) × 15 mL = 30 mL total. Since
1 tablespoon = 15 mL, 30 mL = 2 tablespoons. The nurse should instruct the client to take 2
tablespoons per dose. This is a medication calculation commonly tested on the HESI Exit Exam.
Question 3
The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to
discharge. Which behaviors indicate the client understands how to maintain balance safely?
(Select all that apply)
A) Brings a heavy can close to the body before lifting
B) Locks knees while preparing food on the counter
C) Widens stance while working near the sink
D) Bends from the waist to pick trash off the floor
E) Leans forward to pull a pan from a high shelf
, Answer: A) Brings a heavy can close to the body before lifting; C) Widens stance while
working near the sink
Rationale: Safe body mechanics include keeping heavy objects close to the body to reduce
strain (A), and widening the stance for a broader base of support (C). Locking knees (B) can
cause venous pooling and syncope, bending from the waist (D) strains the lower back, and
leaning forward to reach high objects (E) compromises balance and increases fall risk.
Question 4
The RN is assigned to care for four surgical clients. After receiving report, which client should
the nurse see first?
A) Two days postoperative bladder surgery with continuous bladder irrigation infusing
B) One-day postoperative laparoscopic cholecystectomy requesting pain medication
C) Three days postoperative colon resection receiving a transfusion of packed RBCs
D) Preoperative, in Buck's traction, scheduled for hip arthroplasty within the next 12 hours
Answer: C) Three days postoperative colon resection receiving a transfusion of packed RBCs
Rationale: The client receiving a blood transfusion has the highest priority due to the risk of
transfusion reactions, which can be life-threatening. The nurse must assess this client first to
monitor for signs of a reaction such as fever, chills, hypotension, or respiratory distress. This
question tests prioritization skills using the ABCs and acute safety concerns.
Question 5
A client is receiving a continuous infusion of heparin for treatment of a deep vein thrombosis
(DVT) of the right calf. Which goal should the nurse include in this client's plan of care?
A) No further thrombus will form
B) The client's INR (international normalized ratio) will be 2
C) The existing thrombosis will dissolve
D) The circumference of the client's right calf will decrease
Answer: A) No further thrombus will form
Rationale: The primary goal of heparin therapy is to prevent the extension of the existing
thrombus and to prevent new thrombi from forming. Heparin does not directly dissolve clots—
that is the role of the body's fibrinolytic system over time. INR monitoring is used for warfarin
,Question 1
The nurse is performing preoperative care for a client undergoing an open reduction and
internal fixation (ORIF) of a fractured right tibia. Before the procedure, which action should the
nurse prioritize?
A) Administer preoperative antibiotics
B) Verify the client's signed consent
C) Apply sequential compression devices
D) Start the IV infusion as prescribed
Answer: B) Verify the client's signed consent
Rationale: Before any surgical procedure, verifying that the client has signed the informed
consent form is a legal and ethical priority. Anesthesia or surgery cannot proceed without valid
informed consent. Ensuring that the consent is signed and witnessed protects the patient's
rights and the healthcare facility from liability.
Question 2
A client receives a prescription for acetaminophen 1,000 mg by mouth every 8 hours as needed
for pain. The bottle is labeled "Acetaminophen for Oral Suspension, USP 500 mg per 15 mL."
How many tablespoons should the nurse instruct the client to take with each dose?
Answer: 2 tablespoons
Rationale: Calculation: (1000 mg desired dose ÷ 500 mg available) × 15 mL = 30 mL total. Since
1 tablespoon = 15 mL, 30 mL = 2 tablespoons. The nurse should instruct the client to take 2
tablespoons per dose. This is a medication calculation commonly tested on the HESI Exit Exam.
Question 3
The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to
discharge. Which behaviors indicate the client understands how to maintain balance safely?
(Select all that apply)
A) Brings a heavy can close to the body before lifting
B) Locks knees while preparing food on the counter
C) Widens stance while working near the sink
D) Bends from the waist to pick trash off the floor
E) Leans forward to pull a pan from a high shelf
, Answer: A) Brings a heavy can close to the body before lifting; C) Widens stance while
working near the sink
Rationale: Safe body mechanics include keeping heavy objects close to the body to reduce
strain (A), and widening the stance for a broader base of support (C). Locking knees (B) can
cause venous pooling and syncope, bending from the waist (D) strains the lower back, and
leaning forward to reach high objects (E) compromises balance and increases fall risk.
Question 4
The RN is assigned to care for four surgical clients. After receiving report, which client should
the nurse see first?
A) Two days postoperative bladder surgery with continuous bladder irrigation infusing
B) One-day postoperative laparoscopic cholecystectomy requesting pain medication
C) Three days postoperative colon resection receiving a transfusion of packed RBCs
D) Preoperative, in Buck's traction, scheduled for hip arthroplasty within the next 12 hours
Answer: C) Three days postoperative colon resection receiving a transfusion of packed RBCs
Rationale: The client receiving a blood transfusion has the highest priority due to the risk of
transfusion reactions, which can be life-threatening. The nurse must assess this client first to
monitor for signs of a reaction such as fever, chills, hypotension, or respiratory distress. This
question tests prioritization skills using the ABCs and acute safety concerns.
Question 5
A client is receiving a continuous infusion of heparin for treatment of a deep vein thrombosis
(DVT) of the right calf. Which goal should the nurse include in this client's plan of care?
A) No further thrombus will form
B) The client's INR (international normalized ratio) will be 2
C) The existing thrombosis will dissolve
D) The circumference of the client's right calf will decrease
Answer: A) No further thrombus will form
Rationale: The primary goal of heparin therapy is to prevent the extension of the existing
thrombus and to prevent new thrombi from forming. Heparin does not directly dissolve clots—
that is the role of the body's fibrinolytic system over time. INR monitoring is used for warfarin
