HESI RN EXIT EXAM 800
QUESTIONS AND ANSWERS WITH
RATIONALE 2023 NEW GENERATION
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.
(ANS- Review with the client the need to avoid foods that are rich in milk and
cream
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should
be avoided.
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
(ANS- Stroke secondary to hemorrhage
,Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
hypertension.
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.
c. Assume responsibility for placing the pillows while the UAP completes another
task.
d. Ask the UAP to use some of the pillows to prop the client in a side lying
position.
(ANS- Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows
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
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.
(ANS- Describes life without purpose
Rationale: Cymbalta is a selective serotonin and norepinephrine 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
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.
(ANS- Further evaluation involving surgery may be needed
Rationale: An abdominal mass in a client with a family history for ovarian cancer
should be evaluated carefully
A client who recently underwent 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.
(ANS- Teach tracheal suctioning techniques
Rationale: Suctioning helps to clear secretions and maintain an open airway, which
is critical.
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. 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
(ANS- Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the
client's respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system
alarms. Which client alarm should the nurse investigate first?
, a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
d. Disconnected monitor signal for the last 6 minutes.
(ANS- Respiratory apnea of 30 seconds
Rationale: The priority is the client whose alarm indicating respiratory apnea that
should be assessed first.
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
(ANS- Check the client for lacerations or fractures
Rationale: After the client falls, the nurse should immediately assess for the
possibility of injuries and provide first aid as needed
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.
(ANS- Inform the anesthesia care provider
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 should be notified first.
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2
heart sounds. To determine if an S3 heart sound is present, what action should the
nurse take first
QUESTIONS AND ANSWERS WITH
RATIONALE 2023 NEW GENERATION
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.
(ANS- Review with the client the need to avoid foods that are rich in milk and
cream
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should
be avoided.
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
(ANS- Stroke secondary to hemorrhage
,Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
hypertension.
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.
c. Assume responsibility for placing the pillows while the UAP completes another
task.
d. Ask the UAP to use some of the pillows to prop the client in a side lying
position.
(ANS- Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows
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
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.
(ANS- Describes life without purpose
Rationale: Cymbalta is a selective serotonin and norepinephrine 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
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.
(ANS- Further evaluation involving surgery may be needed
Rationale: An abdominal mass in a client with a family history for ovarian cancer
should be evaluated carefully
A client who recently underwent 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.
(ANS- Teach tracheal suctioning techniques
Rationale: Suctioning helps to clear secretions and maintain an open airway, which
is critical.
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. 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
(ANS- Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the
client's respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system
alarms. Which client alarm should the nurse investigate first?
, a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
d. Disconnected monitor signal for the last 6 minutes.
(ANS- Respiratory apnea of 30 seconds
Rationale: The priority is the client whose alarm indicating respiratory apnea that
should be assessed first.
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
(ANS- Check the client for lacerations or fractures
Rationale: After the client falls, the nurse should immediately assess for the
possibility of injuries and provide first aid as needed
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.
(ANS- Inform the anesthesia care provider
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 should be notified first.
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2
heart sounds. To determine if an S3 heart sound is present, what action should the
nurse take first
