HESI EXIT COMPREHENSIVE PN EXAM A, B AND C (3 LATEST VERSIONS) ACTUAL EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
A nurse who has recently completed orientation is beginning work in the labor and delivery unit for the
first time. When making assignments, which client should the charge nurse assign to this new nurse? -
(answer)A multiparous client who is dilated 5 cm and 50% effaced
A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that
resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish and swallow. Which
information is most important for the nurse to provide the client? -(answer)Oral hygiene should be
performed before the medication.
A client who is admitted with emphysema is having difficulty breathing. In which position should the
nurse place the client? -(answer)Sitting upright and forward with both arms supported on an over the
bed table
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ) PO and 40 mg
of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4
mEq/L. What is the most likely cause of this client's potassium level? -(answer)The client's renal function
has affected his potassium level.
A registered nurse (RN) delivers telehealth services to clients via electronic communication. Which
nursing action creates the greatest risk for professional liability and has the potential for a malpractice
lawsuit? -(answer)Sending medical records to health care providers via the Internet
Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients
with increased intracranial pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated.
B.Higher doses of opioids are required when cerebral blood flow is reduced by an elevated ICP.
C.Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP.
,HESI EXIT COMPREHENSIVE PN EXAM A, B AND C (3 LATEST VERSIONS) ACTUAL EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP. -(answer)D
The greatest risk associated with opioids such as morphine (D) is respiratory depression that causes an
increase in Pco2, which increases ICP and masks the early signs of intracranial bleeding in head injury. (A,
B, and C) do not support the risks associated with opioid use in a client with increased ICP.
The charge nurse of a medical surgical unit is alerted to an impending disaster requiring implementation
of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which
instruction should the charge nurse give to the other staff members at this time?
A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
D.Continue with current assignments until more instructions are received. -(answer)D
When faced with an impending disaster, hospital personnel may be alerted but should continue with
current client care assignments until further instructions are received (D). Evacuation is typically a
response of last resort that begins with clients who are most able to ambulate (A). (B) is premature and
is likely to increase the chaos if incoming casualties are anticipated. (C) is poor utilization of personnel.
The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change
suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the
client's resuscitative status and needs to check the client's medical record for any advanced directives.
Which action should the nurse implement?
A.Ask the UAP to check for the advanced directive while the nurse completes the assessment.
B.Assign the UAP to complete the assessment while the nurse checks for the advanced directive.
C.Check the medical record for the advanced directive and then complete the client assessment.
,HESI EXIT COMPREHENSIVE PN EXAM A, B AND C (3 LATEST VERSIONS) ACTUAL EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
D.Call for the charge nurse to check the advanced directive while continuing to assess the client. -
(answer)D
Because the client's condition is worsening, the nurse should remain with the client and continue the
assessment while calling for help from the charge nurse to determine the client's resuscitative status (D).
(A and B) are tasks that must be completed by a nurse and cannot be delegated to the UAP. (C) is
contraindicated.
The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the nurse. Which task is
important for the nurse to perform, rather than the UAP?
A.Remove the client's nail polish and dentures.
B.Assist the client to the restroom to void.
C.Obtain the client's height and weight.
D.Offer the client emotional support. -(answer)D
By using therapeutic techniques to offer support (D), the nurse can determine any client concerns that
need to be addressed. (A, B, and C) are all actions that can be performed by the UAP under the
supervision of the nurse.
Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who
usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative
unit. Which client would be best for the charge nurse to assign to this UAP?
A.An adolescent who was readmitted to the hospital because of a postoperative infection
B.A woman with a new colostomy who requires discharge teaching
C.A woman who had a hip replacement and may be transferred to the home care unit
D.A man who had a cholecystectomy and currently has a nasogastric tube set to intermittent suction -
(answer)C
, HESI EXIT COMPREHENSIVE PN EXAM A, B AND C (3 LATEST VERSIONS) ACTUAL EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
The charge nurse will be responsible for providing a report to the home care unit if the transfer occurs
(A). The client is infected and an employee who works on an OB unit should be assigned to clean cases in
case the employee is required to return to the OB unit (B). This requires the skills of a registered nurse
(RN) to do discharge teaching and provide emotional support (D). This may require skills beyond the level
of this UAP.
A male client is admitted for observation after being hit on the head with a baseball bat. Six hours after
admission, the client attempts to crawl out of bed and asks the nurse why there are so many bugs in his
bed. His vital signs are stable, and the pulse oximeter reading is 98% on room air. Which intervention
should the nurse perform first?
A.Administer oxygen per nasal cannula at 2 L/min.
B.Plan to check his vital signs again in 30 minutes.
C.Notify the health care provider of the change in mental status.
D.Ask the client why he thinks there are bugs in the bed. -(answer)C
One of the earliest signs of increased intracranial pressure (ICP) is a change in mental status (C). It is
important to act early and quickly when symptoms of increased ICP occur. Because his oxygen saturation
is normal, the administration of oxygen (A) is not the top priority. Vital signs should be monitored
frequently (B), but the client's confusion should be reported immediately. (D) is not a useful intervention.
The nurse is monitoring a client who is receiving bedside conscious sedation with midazolam
hydrochloride (Versed). In assessing the client, the nurse determines that the client has slurred speech
with diplopia. Based on this finding, what action should the nurse take?
A.Open the airway with a chin lift-head tilt maneuver.
B.Obtain a fingerstick glucose reading.
C.Administer flumazenil (Romazicon).
D.Continue to monitor the client. -(answer)D
QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
A nurse who has recently completed orientation is beginning work in the labor and delivery unit for the
first time. When making assignments, which client should the charge nurse assign to this new nurse? -
(answer)A multiparous client who is dilated 5 cm and 50% effaced
A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that
resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish and swallow. Which
information is most important for the nurse to provide the client? -(answer)Oral hygiene should be
performed before the medication.
A client who is admitted with emphysema is having difficulty breathing. In which position should the
nurse place the client? -(answer)Sitting upright and forward with both arms supported on an over the
bed table
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ) PO and 40 mg
of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4
mEq/L. What is the most likely cause of this client's potassium level? -(answer)The client's renal function
has affected his potassium level.
A registered nurse (RN) delivers telehealth services to clients via electronic communication. Which
nursing action creates the greatest risk for professional liability and has the potential for a malpractice
lawsuit? -(answer)Sending medical records to health care providers via the Internet
Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients
with increased intracranial pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated.
B.Higher doses of opioids are required when cerebral blood flow is reduced by an elevated ICP.
C.Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP.
,HESI EXIT COMPREHENSIVE PN EXAM A, B AND C (3 LATEST VERSIONS) ACTUAL EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP. -(answer)D
The greatest risk associated with opioids such as morphine (D) is respiratory depression that causes an
increase in Pco2, which increases ICP and masks the early signs of intracranial bleeding in head injury. (A,
B, and C) do not support the risks associated with opioid use in a client with increased ICP.
The charge nurse of a medical surgical unit is alerted to an impending disaster requiring implementation
of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which
instruction should the charge nurse give to the other staff members at this time?
A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
D.Continue with current assignments until more instructions are received. -(answer)D
When faced with an impending disaster, hospital personnel may be alerted but should continue with
current client care assignments until further instructions are received (D). Evacuation is typically a
response of last resort that begins with clients who are most able to ambulate (A). (B) is premature and
is likely to increase the chaos if incoming casualties are anticipated. (C) is poor utilization of personnel.
The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change
suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the
client's resuscitative status and needs to check the client's medical record for any advanced directives.
Which action should the nurse implement?
A.Ask the UAP to check for the advanced directive while the nurse completes the assessment.
B.Assign the UAP to complete the assessment while the nurse checks for the advanced directive.
C.Check the medical record for the advanced directive and then complete the client assessment.
,HESI EXIT COMPREHENSIVE PN EXAM A, B AND C (3 LATEST VERSIONS) ACTUAL EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
D.Call for the charge nurse to check the advanced directive while continuing to assess the client. -
(answer)D
Because the client's condition is worsening, the nurse should remain with the client and continue the
assessment while calling for help from the charge nurse to determine the client's resuscitative status (D).
(A and B) are tasks that must be completed by a nurse and cannot be delegated to the UAP. (C) is
contraindicated.
The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the nurse. Which task is
important for the nurse to perform, rather than the UAP?
A.Remove the client's nail polish and dentures.
B.Assist the client to the restroom to void.
C.Obtain the client's height and weight.
D.Offer the client emotional support. -(answer)D
By using therapeutic techniques to offer support (D), the nurse can determine any client concerns that
need to be addressed. (A, B, and C) are all actions that can be performed by the UAP under the
supervision of the nurse.
Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who
usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative
unit. Which client would be best for the charge nurse to assign to this UAP?
A.An adolescent who was readmitted to the hospital because of a postoperative infection
B.A woman with a new colostomy who requires discharge teaching
C.A woman who had a hip replacement and may be transferred to the home care unit
D.A man who had a cholecystectomy and currently has a nasogastric tube set to intermittent suction -
(answer)C
, HESI EXIT COMPREHENSIVE PN EXAM A, B AND C (3 LATEST VERSIONS) ACTUAL EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
The charge nurse will be responsible for providing a report to the home care unit if the transfer occurs
(A). The client is infected and an employee who works on an OB unit should be assigned to clean cases in
case the employee is required to return to the OB unit (B). This requires the skills of a registered nurse
(RN) to do discharge teaching and provide emotional support (D). This may require skills beyond the level
of this UAP.
A male client is admitted for observation after being hit on the head with a baseball bat. Six hours after
admission, the client attempts to crawl out of bed and asks the nurse why there are so many bugs in his
bed. His vital signs are stable, and the pulse oximeter reading is 98% on room air. Which intervention
should the nurse perform first?
A.Administer oxygen per nasal cannula at 2 L/min.
B.Plan to check his vital signs again in 30 minutes.
C.Notify the health care provider of the change in mental status.
D.Ask the client why he thinks there are bugs in the bed. -(answer)C
One of the earliest signs of increased intracranial pressure (ICP) is a change in mental status (C). It is
important to act early and quickly when symptoms of increased ICP occur. Because his oxygen saturation
is normal, the administration of oxygen (A) is not the top priority. Vital signs should be monitored
frequently (B), but the client's confusion should be reported immediately. (D) is not a useful intervention.
The nurse is monitoring a client who is receiving bedside conscious sedation with midazolam
hydrochloride (Versed). In assessing the client, the nurse determines that the client has slurred speech
with diplopia. Based on this finding, what action should the nurse take?
A.Open the airway with a chin lift-head tilt maneuver.
B.Obtain a fingerstick glucose reading.
C.Administer flumazenil (Romazicon).
D.Continue to monitor the client. -(answer)D
