HESI EXIT RN EXAM_V1 To V7. lOMoARcPSD|114 501 20
HESI EXIT RN EXAMStuvia.com - The Marketplace to Buy and Sell your Study Material
V1 To V7QUESTIONS & ANSWERS WITH RATIONALE
COMPLETE SOLUTION (LATEST AND UPDATED2020-2021)
1. 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?
a- Remind the client that it is also important to switch to decaffeinated
coffee and tea.
b- Suggest that the client also plan to eat frequent small meals to
reduce discomfort
c- Review with the client the need to avoid foods that are rich in
milk and cream.
d- Reinforce this teaching by asking the client to list a dairy food that he
might select.
Rationale: Diets rich in milk and cream stimulate gastric acid secretion
and should be avoided.
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- Blindness secondary to cataracts
b- Acute kidney injury due to glomerular damage
c- Stroke secondary to hemorrhage
d- Heart block due to myocardial damage
Rationale: Stroke related to cerebral hemorrhage is major risk for
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,HESI EXIT RN EXAM_V1 To V7. lOMoARcPSD|114 501 20
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uncontrolled hypertension.
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- Ensure that the UAP has placed the pillows effectively to protect the
client.
b- Instruct the UAP to obtain soft blankets to secure to the side rails
instead of pillows.
a- Assume responsibility for placing the pillows while the UAP
completes another task.
b- Ask the UAP to use some of the pillows to prop the client in a side
lying position.
Rationale: 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
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
b- Complains of nausea and loss of appetite
c- States is often fatigued and drowsy
d- Exhibits an increase in sweating.
Rationale: Cymbalta is a selective serotonin and norepinephrine
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,HESI EXIT RN EXAM_V1 To V7. lOMoARcPSD|114 501 20
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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
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
b- A pelvic exam is also needed before cancer is ruled out
c- Pap smear evaluation should be continued every six month
d- One additional negative pap smear in six months is needed.
Rationale: An abdominal mass in a client with a family history for
ovarian cancer should be evaluated carefully
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- Explain how to use communication tools.
b- Teach tracheal suctioning techniques
c- Encourage self-care and independence.
d- Demonstrate how to clean tracheostomy site.
Rationale: Suctioning helps to clear secretions and maintain an open
airway, which is critical.
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?
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, HESI EXIT RN EXAM_V1 To V7. lOMoARcPSD|114 501 20
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a- Encourage the client to take deep breaths
b- Remove the mask to deflate the bag
c- Increase the liter flow of oxygen
d- Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration
and the client’s respiratory rate is within normal limits.
8. During a home visit, the nurse observed an elderly client with
diabetes slip and fall. What action should the nurse take first?
a- Give the client 4 ounces of orange juice
b- Call 911 to summon emergency assistance
c- Check the client for lacerations or fractures
d- Asses clients blood sugar level
Rationale: After the client falls, the nurse should immediately assess for
the possibility of injuries and provide first aid as needed
9. 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?
a- Ensure preoperative lab results are available
b- Start prescribed IV with lactated Ringer’s
c- Inform the anesthesia care provider
d- Contact the client’s obstetrician.
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
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HESI EXIT RN EXAMStuvia.com - The Marketplace to Buy and Sell your Study Material
V1 To V7QUESTIONS & ANSWERS WITH RATIONALE
COMPLETE SOLUTION (LATEST AND UPDATED2020-2021)
1. 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?
a- Remind the client that it is also important to switch to decaffeinated
coffee and tea.
b- Suggest that the client also plan to eat frequent small meals to
reduce discomfort
c- Review with the client the need to avoid foods that are rich in
milk and cream.
d- Reinforce this teaching by asking the client to list a dairy food that he
might select.
Rationale: Diets rich in milk and cream stimulate gastric acid secretion
and should be avoided.
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- Blindness secondary to cataracts
b- Acute kidney injury due to glomerular damage
c- Stroke secondary to hemorrhage
d- Heart block due to myocardial damage
Rationale: Stroke related to cerebral hemorrhage is major risk for
Downloaded by: redsautobody23 |
Downloaded by D
DiJstp
rio
bpup
tion op
y pa f sth(isbla
do
ckcsutm
oneenptoispp
illyem
)
,HESI EXIT RN EXAM_V1 To V7. lOMoARcPSD|114 501 20
Stuvia.com - The Marketplace to Buy and Sell your Study Material
uncontrolled hypertension.
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- Ensure that the UAP has placed the pillows effectively to protect the
client.
b- Instruct the UAP to obtain soft blankets to secure to the side rails
instead of pillows.
a- Assume responsibility for placing the pillows while the UAP
completes another task.
b- Ask the UAP to use some of the pillows to prop the client in a side
lying position.
Rationale: 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
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
b- Complains of nausea and loss of appetite
c- States is often fatigued and drowsy
d- Exhibits an increase in sweating.
Rationale: Cymbalta is a selective serotonin and norepinephrine
Downloaded by: redsautobody23 |
Downloaded by D
DiJstp
rio
bpup
tion op
y pa f sth(isbla
do
ckcsutm
oneenptoispp
illyem
)
,HESI EXIT RN EXAM_V1 To V7. lOMoARcPSD|114 501 20
Stuvia.com - The Marketplace to Buy and Sell your Study Material
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
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
b- A pelvic exam is also needed before cancer is ruled out
c- Pap smear evaluation should be continued every six month
d- One additional negative pap smear in six months is needed.
Rationale: An abdominal mass in a client with a family history for
ovarian cancer should be evaluated carefully
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- Explain how to use communication tools.
b- Teach tracheal suctioning techniques
c- Encourage self-care and independence.
d- Demonstrate how to clean tracheostomy site.
Rationale: Suctioning helps to clear secretions and maintain an open
airway, which is critical.
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?
Downloaded by: redsautobody23 |
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rio
bpup
tion op
y pa f sth(isbla
do
ckcsutm
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illyem
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, HESI EXIT RN EXAM_V1 To V7. lOMoARcPSD|114 501 20
Stuvia.com - The Marketplace to Buy and Sell your Study Material
a- Encourage the client to take deep breaths
b- Remove the mask to deflate the bag
c- Increase the liter flow of oxygen
d- Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration
and the client’s respiratory rate is within normal limits.
8. During a home visit, the nurse observed an elderly client with
diabetes slip and fall. What action should the nurse take first?
a- Give the client 4 ounces of orange juice
b- Call 911 to summon emergency assistance
c- Check the client for lacerations or fractures
d- Asses clients blood sugar level
Rationale: After the client falls, the nurse should immediately assess for
the possibility of injuries and provide first aid as needed
9. 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?
a- Ensure preoperative lab results are available
b- Start prescribed IV with lactated Ringer’s
c- Inform the anesthesia care provider
d- Contact the client’s obstetrician.
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
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