HESI Exit Final Exam Questions With
New Update Solutions
/. The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral
care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the
following is the MOST appropriate action for the nurse to take? - Answer-✅Leave the
cuff inflated and suction through the tracheostomy.
/.A young adult brings a friend to the emergency department and states that the friend
has been using heroin. Which action by the nurse is the MOST appropriate? - Answer-
✅Assess oxygen saturation levels.
/.The client tells the clinic nurse that the client is thinking about using nicotine polacrilex
(Nicorette). Which question is MOST important for the nurse to ask? - Answer-✅"Have
you ever had chest pain?"
/.The nurse cares for the client with a client controlled analgesia (PCA) pump. The
nurse determines that the client has pressed the button 11 times and received 6 doses
of morphine during the last hour. Which is the MOST appropriate action for the nurse to
take? - Answer-✅Ask the client to describe the pain.
Assessment: outcome priority; must validate that client is in pain before implementation
/.A pregnant woman receives an epidural anesthetic. After administration of the epidural
anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by
the nurse is MOST appropriate? - Answer-✅Place the client on her left side with her
legs flexed.
Implementation: outcome desired; will increase venous return and cardiac output; fetal
pressure on inferior vena cava reduced
/.A nursing order, "Increase fluid intake" is written for a client diagnosed with
dehydration. Which finding BEST indicates improving fluid status? - Answer-✅Urinary
output of 1,500 mL in 24 hours.
Assessment: outcome priority; increased amounts of antidiuretic hormone secreted;
urine output decreased and concentrated
, /.The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in
the morning. Which medication should the nurse question giving to the client? - Answer-
✅40 mg oral furosemide (Lasix) in the morning.
Implementation: outcome potential problem; may promote significant diuresis; first dose
of ACE inhibitors increases risk of "first dose" phenomenon due to vasodilation;
combination of vasodilation and diuresis increases risk of orthostatic hypotension
/.The home care nurse visits a client with a halo fixator traction device. Which client
statement MOST concerns the nurse? - Answer-✅"I drove to the library yesterday."
Implementation: outcome not desired and may be a problem; client is not able to turn
with halo device; increases the risk of injury to self and others
/.The nurse cares for a client diagnosed with depression. Which statement by the client
indicates improvement? - Answer-✅The nurse cares for a client diagnosed with
depression. Which statement by the client indicates improvement?
The nurse cares for a client diagnosed with depression. Which statement by the client
indicates improvement?
/.The nurse on the maternity unit must accept a transfer client from a medical/surgical
unit. The nurse considers which transfer client appropriate? - Answer-✅A 38-year-old
client with a diagnosis of systemic lupus erythematosus.
Implementation: outcome desired; autoimmune disease; not infectious
/.The nurse in the outclient surgery unit prepares a 4-year-old child for surgery. It is
MOST important for the nurse to make which of these statements? - Answer-✅"Take
this doll and show me where the operation will be done."
Implementation: outcome desired; encourage expression of feelings (e.g., anger); fear
mutilation; allow child to play with models of equipment
/.The nurse cares for a client diagnosed with Alzheimer's disease. The client is confused
and incontinent of urine. What is the MOST important action for the nurse to take? -
Answer-✅Assist the client to a bedside commode every 2 hours.
Implementation: outcome desired; keeps client active and independent
/.The nurse cares for a client with a history of type 1 diabetes mellitus who has just
returned to the surgical acute-care unit after a right below-knee amputation. The client's
capillary blood glucose is 480 mg/dL. The postoperative orders indicate 6 units of
regular insulin subcutaneously should be administered. Which of the following is the
New Update Solutions
/. The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral
care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the
following is the MOST appropriate action for the nurse to take? - Answer-✅Leave the
cuff inflated and suction through the tracheostomy.
/.A young adult brings a friend to the emergency department and states that the friend
has been using heroin. Which action by the nurse is the MOST appropriate? - Answer-
✅Assess oxygen saturation levels.
/.The client tells the clinic nurse that the client is thinking about using nicotine polacrilex
(Nicorette). Which question is MOST important for the nurse to ask? - Answer-✅"Have
you ever had chest pain?"
/.The nurse cares for the client with a client controlled analgesia (PCA) pump. The
nurse determines that the client has pressed the button 11 times and received 6 doses
of morphine during the last hour. Which is the MOST appropriate action for the nurse to
take? - Answer-✅Ask the client to describe the pain.
Assessment: outcome priority; must validate that client is in pain before implementation
/.A pregnant woman receives an epidural anesthetic. After administration of the epidural
anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by
the nurse is MOST appropriate? - Answer-✅Place the client on her left side with her
legs flexed.
Implementation: outcome desired; will increase venous return and cardiac output; fetal
pressure on inferior vena cava reduced
/.A nursing order, "Increase fluid intake" is written for a client diagnosed with
dehydration. Which finding BEST indicates improving fluid status? - Answer-✅Urinary
output of 1,500 mL in 24 hours.
Assessment: outcome priority; increased amounts of antidiuretic hormone secreted;
urine output decreased and concentrated
, /.The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in
the morning. Which medication should the nurse question giving to the client? - Answer-
✅40 mg oral furosemide (Lasix) in the morning.
Implementation: outcome potential problem; may promote significant diuresis; first dose
of ACE inhibitors increases risk of "first dose" phenomenon due to vasodilation;
combination of vasodilation and diuresis increases risk of orthostatic hypotension
/.The home care nurse visits a client with a halo fixator traction device. Which client
statement MOST concerns the nurse? - Answer-✅"I drove to the library yesterday."
Implementation: outcome not desired and may be a problem; client is not able to turn
with halo device; increases the risk of injury to self and others
/.The nurse cares for a client diagnosed with depression. Which statement by the client
indicates improvement? - Answer-✅The nurse cares for a client diagnosed with
depression. Which statement by the client indicates improvement?
The nurse cares for a client diagnosed with depression. Which statement by the client
indicates improvement?
/.The nurse on the maternity unit must accept a transfer client from a medical/surgical
unit. The nurse considers which transfer client appropriate? - Answer-✅A 38-year-old
client with a diagnosis of systemic lupus erythematosus.
Implementation: outcome desired; autoimmune disease; not infectious
/.The nurse in the outclient surgery unit prepares a 4-year-old child for surgery. It is
MOST important for the nurse to make which of these statements? - Answer-✅"Take
this doll and show me where the operation will be done."
Implementation: outcome desired; encourage expression of feelings (e.g., anger); fear
mutilation; allow child to play with models of equipment
/.The nurse cares for a client diagnosed with Alzheimer's disease. The client is confused
and incontinent of urine. What is the MOST important action for the nurse to take? -
Answer-✅Assist the client to a bedside commode every 2 hours.
Implementation: outcome desired; keeps client active and independent
/.The nurse cares for a client with a history of type 1 diabetes mellitus who has just
returned to the surgical acute-care unit after a right below-knee amputation. The client's
capillary blood glucose is 480 mg/dL. The postoperative orders indicate 6 units of
regular insulin subcutaneously should be administered. Which of the following is the
