PN HESI Exit Exam V1: The Ultimate -
Question Practice Test with Rationales
1. A nurse is caring for a client who is 4 hours post-operative following
a cholecystectomy. The client reports severe pain in the right shoulder.
Which of the following actions should the nurse take?
A) Apply a warm compress to the right shoulder.
B) Notify the provider immediately.
C) Administer the prescribed PRN analgesic.
D) Position the client in a left lateral Trendelenburg position.
Correct Answer: A) Apply a warm compress to the right shoulder.
Rationale: This is a classic finding of referred pain from the diaphragm due
to carbon dioxide (CO2) gas used during laparoscopic surgery. The gas
irritates the phrenic nerve, causing pain in the shoulder. This is an expected,
temporary side effect and does not indicate a complication. Applying a
warm compress provides comfort. Notifying the provider or administering
an analgesic would be appropriate if the pain is unmanageable, but the
nurse should first attempt non-pharmacological measures.
2. A nurse is reinforcing teaching with a client who has a new
prescription for an albuterol metered-dose inhaler (MDI). Which of the
following instructions should the nurse include?
A) "Wait 5 seconds between puffs."
B) "Inhale the medication quickly and deeply."
C) "Rinse your mouth with water after using the inhaler."
, D) "Use the inhaler for acute shortness of breath only."
Correct Answer: C) "Rinse your mouth with water after using the
inhaler."
Rationale: Albuterol is a bronchodilator. Rinsing the mouth after inhalation
helps prevent oropharyngeal irritation and a fungal infection called oral
candidiasis (thrush). The correct technique is to wait 1-2 minutes between
puffs, inhale the medication slowly and deeply, and use it as a scheduled
maintenance medication for bronchospasm, not just for acute attacks.
3. A nurse is caring for a client who has a newly placed tracheostomy.
Which of the following findings should the nurse report to the
provider immediately?
A) The client's heart rate is 88/min.
B) The client has small amounts of blood-tinged sputum.
C) The client's respiratory rate is 14/min.
D) The client has subcutaneous emphysema around the stoma.
Correct Answer: D) The client has subcutaneous emphysema around
the stoma.
Rationale: Subcutaneous emphysema (air trapped under the skin, causing
a crackling sensation) indicates a potential air leak from the trachea, which
can compromise the airway. This is an emergent finding that requires
immediate notification of the provider. A small amount of blood-tinged
sputum is expected in the first 24-48 hours.
4. A nurse is preparing to administer 0.9% sodium chloride 500 mL IV
over 4 hours. The drop factor of the manual IV tubing is 15 gtt/mL.
, The nurse should set the IV flow rate to deliver how many gtt/min?
(Round to the nearest whole number.)
Correct Answer: 31 gtt/min
Rationale: Use the formula: (Total volume in mL / Total time in minutes) x
Drop factor (gtt/mL) = gtt/min.
(500 mL / 240 minutes) x 15 gtt/mL = 31.25, which rounds to 31 gtt/min.
5. A nurse is caring for a client with dementia who becomes agitated
and attempts to hit the nursing assistant. Which of the following is the
priority nursing action?
A) Place the client in a seclusion room.
B) Administer a PRN sedative medication.
C) Assess the client for unmet needs (e.g., pain, hunger, toileting).
D) Restrain the client to prevent injury to others.
Correct Answer: C) Assess the client for unmet needs.
Rationale: The first step is to assess the client. Agitation in dementia is
often a form of communication for an unmet need, such as pain, hunger,
thirst, or the need to use the bathroom. Restraints and seclusion should
only be used as a last resort when the client is a danger to themselves or
others, and only after a thorough assessment.
6. A nurse is reinforcing discharge teaching to a client with a new
colostomy. Which of the following statements by the client indicates a
need for further teaching?
A) "I should avoid foods that cause gas, like beans and broccoli."
B) "I will change the ostomy pouch every day."
C) "I can take a shower with the pouch on."
D) "I should empty the pouch when it's one-third to one-half full."
Question Practice Test with Rationales
1. A nurse is caring for a client who is 4 hours post-operative following
a cholecystectomy. The client reports severe pain in the right shoulder.
Which of the following actions should the nurse take?
A) Apply a warm compress to the right shoulder.
B) Notify the provider immediately.
C) Administer the prescribed PRN analgesic.
D) Position the client in a left lateral Trendelenburg position.
Correct Answer: A) Apply a warm compress to the right shoulder.
Rationale: This is a classic finding of referred pain from the diaphragm due
to carbon dioxide (CO2) gas used during laparoscopic surgery. The gas
irritates the phrenic nerve, causing pain in the shoulder. This is an expected,
temporary side effect and does not indicate a complication. Applying a
warm compress provides comfort. Notifying the provider or administering
an analgesic would be appropriate if the pain is unmanageable, but the
nurse should first attempt non-pharmacological measures.
2. A nurse is reinforcing teaching with a client who has a new
prescription for an albuterol metered-dose inhaler (MDI). Which of the
following instructions should the nurse include?
A) "Wait 5 seconds between puffs."
B) "Inhale the medication quickly and deeply."
C) "Rinse your mouth with water after using the inhaler."
, D) "Use the inhaler for acute shortness of breath only."
Correct Answer: C) "Rinse your mouth with water after using the
inhaler."
Rationale: Albuterol is a bronchodilator. Rinsing the mouth after inhalation
helps prevent oropharyngeal irritation and a fungal infection called oral
candidiasis (thrush). The correct technique is to wait 1-2 minutes between
puffs, inhale the medication slowly and deeply, and use it as a scheduled
maintenance medication for bronchospasm, not just for acute attacks.
3. A nurse is caring for a client who has a newly placed tracheostomy.
Which of the following findings should the nurse report to the
provider immediately?
A) The client's heart rate is 88/min.
B) The client has small amounts of blood-tinged sputum.
C) The client's respiratory rate is 14/min.
D) The client has subcutaneous emphysema around the stoma.
Correct Answer: D) The client has subcutaneous emphysema around
the stoma.
Rationale: Subcutaneous emphysema (air trapped under the skin, causing
a crackling sensation) indicates a potential air leak from the trachea, which
can compromise the airway. This is an emergent finding that requires
immediate notification of the provider. A small amount of blood-tinged
sputum is expected in the first 24-48 hours.
4. A nurse is preparing to administer 0.9% sodium chloride 500 mL IV
over 4 hours. The drop factor of the manual IV tubing is 15 gtt/mL.
, The nurse should set the IV flow rate to deliver how many gtt/min?
(Round to the nearest whole number.)
Correct Answer: 31 gtt/min
Rationale: Use the formula: (Total volume in mL / Total time in minutes) x
Drop factor (gtt/mL) = gtt/min.
(500 mL / 240 minutes) x 15 gtt/mL = 31.25, which rounds to 31 gtt/min.
5. A nurse is caring for a client with dementia who becomes agitated
and attempts to hit the nursing assistant. Which of the following is the
priority nursing action?
A) Place the client in a seclusion room.
B) Administer a PRN sedative medication.
C) Assess the client for unmet needs (e.g., pain, hunger, toileting).
D) Restrain the client to prevent injury to others.
Correct Answer: C) Assess the client for unmet needs.
Rationale: The first step is to assess the client. Agitation in dementia is
often a form of communication for an unmet need, such as pain, hunger,
thirst, or the need to use the bathroom. Restraints and seclusion should
only be used as a last resort when the client is a danger to themselves or
others, and only after a thorough assessment.
6. A nurse is reinforcing discharge teaching to a client with a new
colostomy. Which of the following statements by the client indicates a
need for further teaching?
A) "I should avoid foods that cause gas, like beans and broccoli."
B) "I will change the ostomy pouch every day."
C) "I can take a shower with the pouch on."
D) "I should empty the pouch when it's one-third to one-half full."
