HESI EXIT 2025 EXAM GRADED A WITH
ACTUAL QUESTIONS AND CORRECT
ANSWERS
While assessing a radial artery catheter, the client complains of numbness and
pain distal to the insertion site. What interventions should the nurse
implement? - CORRECT ANSWER-Promptly remove the arterial catheter from
the radial artery.
A client is admitted with an epidural hematoma that resulted from a
skateboarding accident. To differentiate the vascular source of the intracranial
bleeding, which finding should the nurse monitor? - CORRECT ANSWER-Rapid
onset of decreased level of consciousness.
When preparing a client for discharge from the hospital following a cystectomy
and a urinary diversion to treat bladder cancer, which instruction is most
important for the nurse to include in the client's discharge teaching plan? -
CORRECT ANSWER-Report any signs of cloudy urine output.
After repositioning an immobile client, the nurse observes an area of
hyperemia. To assess for blanching, what action should the nurse take? -
CORRECT ANSWER-Apply light pressure over the area.
The nurse enters a client's room and observes the client's wrist restraint
secured as seen in the picture. What action should the nurse take? - CORRECT
ANSWER-Reposition the restraint tie onto the bedframe.
,A female client with acute respiratory distress syndrome (ARDS) is chemically
paralyzed and sedated while she is on as assist-control ventilator using 50%
FIO2. Which assessment finding warrants
immediate intervention by the nurse? - CORRECT ANSWER-Diminished left
lower lobe sounds
Rationale: Diminished lobe sounds indicate collapsed alveoli or tension
pneumothorax, which required
immediate chest tube insertion to re-inflate the lung.
Following a motor vehicle collision, an adult female with a ruptured spleen and
a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after
the surgery, her urine output is 25 ml/hour for the last two hours. What
pathophysiological reason supports the nurse's decision to report this finding
to the healthcare provider? - CORRECT ANSWER-Oliguria signals tubular
necrosis related to hypoperfusion
A nurse-manager is preparing the curricula for a class for charge nurses. A
staffing formula based on what data ensures quality client care and is most
cost-effective? - CORRECT ANSWER-Skills of staff and client acuity
When performing postural drainage on a client with Chronic Obstructive
Pulmonary Disease (COPD), which approach should the nurse use? - CORRECT
ANSWER-Explain that the client may be placed in five positions
A client presents in the emergency room with right-sided facial asymmetry. The
nurse asks the client to perform a series of movements that require use of the
facial muscles. What symptoms suggest that the client has most likely
experience a Bell's palsy rather than a stroke? - CORRECT ANSWER-Inability to
close the affected eye, raise brow, or smile
,The nurse is teaching a client how to perform colostomy irrigations. When
observing the client's return demonstration, which action indicated that the
client understood the teaching? - CORRECT ANSWER-Keeps the irrigating
container less than 18 inches above the stoma
The nurse should teach the client to observe which precaution while taking
dronedarone? - CORRECT ANSWER-Avoid grapefruits and its juice
A client who sustained a head injury following an automobile collision is
admitted to the hospital. The nurse include the client's risk for developing
increased intracranial pressure (ICP) in the plan of care. Which signs indicate to
the nurse that ICP has increased? - CORRECT ANSWER-Increased Glasgow coma
scale score.
Nuchal rigidity and papilledema.
Confusion and papilledema
Periorbital ecchymosis.
Rationale: papilledema is always an indicator of increased ICP, and confusion is
usually the first sign of
increased ICP. Other options do not necessarily reflect increased ICP.
The nurse is caring for a client receiving continuous IV fluids through a single
lumen central venous catheter (CVC). Based on the CVC care bundle, which
action should be completed daily to reduce the
risk for infection? - CORRECT ANSWER-Confirm the necessity for continued use
of the CVC.
During an annual physical examination, an older woman's fasting blood sugar
(FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional
, finding obtained during a follow-up visit 2 weeks later is most indicative that
the client has diabetes mellitus (DM)? - CORRECT ANSWER-Repeated fasting
blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
A client who was admitted yesterday with severe dehydration is complaining of
pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour.
Which intervention should the nurse implement first? - CORRECT ANSWER-
Stop the normal saline infusion.
An elderly female is admitted because of a change in her level of sensorium.
During the evening shift, the client attempts to get out bed and falls, breaking
her left hip. Buck's skin traction is applied to the left leg while waiting for
surgery. Which intervention is most important for the nurse to include in this
client's plan care? - CORRECT ANSWER-Ensure proper alignment of the leg in
traction.
A client who had a right hip replacement 3 day ago is pale has diminished
breath sound over the left lower lung fields, a temperature of 100.2 F, and an
oxygen saturation rate of 90%. The client is scheduled to be transferred to a
skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based
on the client's symptoms, what recommendation should the nurse give the
healthcare provider? - CORRECT ANSWER-Reassess readiness for SNF transfer.
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a
prescription for metformin (Glucophage) 500 mg PO twice daily. What
information should the nurse include in this client's teaching plan? (Select all
that apply.) - CORRECT ANSWER-Recognize signs and symptoms of
hypoglycemia.
Report persist polyuria to the healthcare provider.
Take Glucophage with the morning and evening meal.
ACTUAL QUESTIONS AND CORRECT
ANSWERS
While assessing a radial artery catheter, the client complains of numbness and
pain distal to the insertion site. What interventions should the nurse
implement? - CORRECT ANSWER-Promptly remove the arterial catheter from
the radial artery.
A client is admitted with an epidural hematoma that resulted from a
skateboarding accident. To differentiate the vascular source of the intracranial
bleeding, which finding should the nurse monitor? - CORRECT ANSWER-Rapid
onset of decreased level of consciousness.
When preparing a client for discharge from the hospital following a cystectomy
and a urinary diversion to treat bladder cancer, which instruction is most
important for the nurse to include in the client's discharge teaching plan? -
CORRECT ANSWER-Report any signs of cloudy urine output.
After repositioning an immobile client, the nurse observes an area of
hyperemia. To assess for blanching, what action should the nurse take? -
CORRECT ANSWER-Apply light pressure over the area.
The nurse enters a client's room and observes the client's wrist restraint
secured as seen in the picture. What action should the nurse take? - CORRECT
ANSWER-Reposition the restraint tie onto the bedframe.
,A female client with acute respiratory distress syndrome (ARDS) is chemically
paralyzed and sedated while she is on as assist-control ventilator using 50%
FIO2. Which assessment finding warrants
immediate intervention by the nurse? - CORRECT ANSWER-Diminished left
lower lobe sounds
Rationale: Diminished lobe sounds indicate collapsed alveoli or tension
pneumothorax, which required
immediate chest tube insertion to re-inflate the lung.
Following a motor vehicle collision, an adult female with a ruptured spleen and
a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after
the surgery, her urine output is 25 ml/hour for the last two hours. What
pathophysiological reason supports the nurse's decision to report this finding
to the healthcare provider? - CORRECT ANSWER-Oliguria signals tubular
necrosis related to hypoperfusion
A nurse-manager is preparing the curricula for a class for charge nurses. A
staffing formula based on what data ensures quality client care and is most
cost-effective? - CORRECT ANSWER-Skills of staff and client acuity
When performing postural drainage on a client with Chronic Obstructive
Pulmonary Disease (COPD), which approach should the nurse use? - CORRECT
ANSWER-Explain that the client may be placed in five positions
A client presents in the emergency room with right-sided facial asymmetry. The
nurse asks the client to perform a series of movements that require use of the
facial muscles. What symptoms suggest that the client has most likely
experience a Bell's palsy rather than a stroke? - CORRECT ANSWER-Inability to
close the affected eye, raise brow, or smile
,The nurse is teaching a client how to perform colostomy irrigations. When
observing the client's return demonstration, which action indicated that the
client understood the teaching? - CORRECT ANSWER-Keeps the irrigating
container less than 18 inches above the stoma
The nurse should teach the client to observe which precaution while taking
dronedarone? - CORRECT ANSWER-Avoid grapefruits and its juice
A client who sustained a head injury following an automobile collision is
admitted to the hospital. The nurse include the client's risk for developing
increased intracranial pressure (ICP) in the plan of care. Which signs indicate to
the nurse that ICP has increased? - CORRECT ANSWER-Increased Glasgow coma
scale score.
Nuchal rigidity and papilledema.
Confusion and papilledema
Periorbital ecchymosis.
Rationale: papilledema is always an indicator of increased ICP, and confusion is
usually the first sign of
increased ICP. Other options do not necessarily reflect increased ICP.
The nurse is caring for a client receiving continuous IV fluids through a single
lumen central venous catheter (CVC). Based on the CVC care bundle, which
action should be completed daily to reduce the
risk for infection? - CORRECT ANSWER-Confirm the necessity for continued use
of the CVC.
During an annual physical examination, an older woman's fasting blood sugar
(FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional
, finding obtained during a follow-up visit 2 weeks later is most indicative that
the client has diabetes mellitus (DM)? - CORRECT ANSWER-Repeated fasting
blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
A client who was admitted yesterday with severe dehydration is complaining of
pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour.
Which intervention should the nurse implement first? - CORRECT ANSWER-
Stop the normal saline infusion.
An elderly female is admitted because of a change in her level of sensorium.
During the evening shift, the client attempts to get out bed and falls, breaking
her left hip. Buck's skin traction is applied to the left leg while waiting for
surgery. Which intervention is most important for the nurse to include in this
client's plan care? - CORRECT ANSWER-Ensure proper alignment of the leg in
traction.
A client who had a right hip replacement 3 day ago is pale has diminished
breath sound over the left lower lung fields, a temperature of 100.2 F, and an
oxygen saturation rate of 90%. The client is scheduled to be transferred to a
skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based
on the client's symptoms, what recommendation should the nurse give the
healthcare provider? - CORRECT ANSWER-Reassess readiness for SNF transfer.
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a
prescription for metformin (Glucophage) 500 mg PO twice daily. What
information should the nurse include in this client's teaching plan? (Select all
that apply.) - CORRECT ANSWER-Recognize signs and symptoms of
hypoglycemia.
Report persist polyuria to the healthcare provider.
Take Glucophage with the morning and evening meal.
