HESI Exit Exam Test Bank ACTUAL EXAM 500
QUESTIONS AND CORRECT DETAILED ANSWERS
A. Ask the client to bear down as if voiding to relax the sphincter
C. Complete perianal care with soap and water
D. Gently palpate the client’s bladder for distention
E. Hold the catheter 3 – 4 inches (7.5 – 10 cm) from its tip
F. Secure the urinary drainage bag to the bed frame
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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?
A. Review with the client the need to avoid foods that
are rich in milk and cream
2. 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? A. Stroke
secondary to hemorrhage
3. 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? A. Instruct the UAP to obtain soft
, blankets to secure to the side rails instead of
pillows.
4. An adolescent with major depressive disorder
has been taking duloxetine (Cymbalta) for the
past 12 days. Which assessment finding requires
immediate follow-up? A. Describes life without
purpose
5. A 60-year-old female client with a positive family
history of ovarian cancer has developed an
abdominal mass and is being evaluated for
possible ovarian cancer. Her Papanicolau (Pap)
smear results are negative. What information
should the nurse include in the client’s teaching
plan?
A. Further evaluation involving surgery may be
needed
6. A client who recently underwear a tracheostomy is
being prepared for discharge to home. Which
instructions is most important for the nurse to
include in the discharge plan?
A. Teach tracheal suctioning techniques
7. 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?
A. Document the assessment data
B. Rational: reservoir bag should not deflate
completely during inspiration and the client’s
respiratory rate is within normal limits.
8. During shift report, the central electrocardiogram
(EKG) monitoring system alarms. Which client
alarm should the nurse investigate firs?
A. Respiratory apnea of 30 seconds
9. During a home visit, the nurse observed an elderly
client with diabetes slip and fall. What action should
the nurse take first?
A. Check the client for lacerations or fractures
10. 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?
QUESTIONS AND CORRECT DETAILED ANSWERS
A. Ask the client to bear down as if voiding to relax the sphincter
C. Complete perianal care with soap and water
D. Gently palpate the client’s bladder for distention
E. Hold the catheter 3 – 4 inches (7.5 – 10 cm) from its tip
F. Secure the urinary drainage bag to the bed frame
, 1.Following discShtuavirag.ceomt-
eTahechMianrkget,plaacemtoaBluey
acnldieSnelltyowuritShtuddyuMoadteerianl al
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?
A. Review with the client the need to avoid foods that
are rich in milk and cream
2. 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? A. Stroke
secondary to hemorrhage
3. 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? A. Instruct the UAP to obtain soft
, blankets to secure to the side rails instead of
pillows.
4. An adolescent with major depressive disorder
has been taking duloxetine (Cymbalta) for the
past 12 days. Which assessment finding requires
immediate follow-up? A. Describes life without
purpose
5. A 60-year-old female client with a positive family
history of ovarian cancer has developed an
abdominal mass and is being evaluated for
possible ovarian cancer. Her Papanicolau (Pap)
smear results are negative. What information
should the nurse include in the client’s teaching
plan?
A. Further evaluation involving surgery may be
needed
6. A client who recently underwear a tracheostomy is
being prepared for discharge to home. Which
instructions is most important for the nurse to
include in the discharge plan?
A. Teach tracheal suctioning techniques
7. 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?
A. Document the assessment data
B. Rational: reservoir bag should not deflate
completely during inspiration and the client’s
respiratory rate is within normal limits.
8. During shift report, the central electrocardiogram
(EKG) monitoring system alarms. Which client
alarm should the nurse investigate firs?
A. Respiratory apnea of 30 seconds
9. During a home visit, the nurse observed an elderly
client with diabetes slip and fall. What action should
the nurse take first?
A. Check the client for lacerations or fractures
10. 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?
