HESI 799 RN Exit Exam #5 – Questions &
Answers | Latest Update 2026 | Exam Prep
PDF | Graded A+
An adult client is exhibit the manic stage of bipolar disorder is admitted to the psychiatric
unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week
"I'm trying to start a new business and "I'm too busy to eat". The client is oriented to
time, place, person but not situation. Which nursing problem has the greatest priority?
a. Hygiene-self-care deficit
b. Imbalance nutrition
c. Disturbed sleep pattern
d. Self-neglect - correct answerImbalance nutrition
Rationale: The client's nutritional status has the highest priority at this time, and finger
foods are often provided, so the client who is on the maniac phase of bipolar disease
can receive adequate nutrition. Other options are nursing problems that should also be
addresses with the client's plan of care, but at this stage in the client's treatment,
adequate nutrition is a priority
A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks
ago returns to the clinic for a follow up visit. The client has a postoperative ejection
fraction ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal
edema, and a 5pound weight gain. Which intervention the nurse implement?
a. Arrange transport for admission to the hospital.
b. Insert saline lock for IV diuretic therapy.
c. Assess compliance with routine prescriptions.
d. Instruct the client to monitor daily caloric intake. - correct answerAssess compliance
with routine prescriptions.
Rationale: Fluid retention may be a sign that the client is not taking the medication as
prescribed or that the prescriptions may need adjustment to manage cardiac function
post-PTCA (normal ejection fraction range is 50 to 75%)
The nurse is assessing a client's nailbeds. Witch appearance indicates further follow-up
is needed for problems associated with chronic hypoxia?
Clubbing FLIP for photo!!! - correct answerclubbing
The RN is assigned to care for four surgical clients. After receiving report, which client
should the nurse see first? The client who is:
,a. Two days postoperative bladder surgery with continuous bladder irrigation infusing.
b. One day postoperative laparoscopic cholecystectomy requesting pain medication.
c. Three days postoperative colon resection receiving transfusion of packed RBCs.
d. Preoperative, in buck's traction, and scheduled for hip arthroplasty within the next 12
hours. - correct answerThree days postoperative colon resection receiving transfusion
of packed RBCs.
The nurse is preparing an older client for discharge following cataract extraction. Which
instruction should be include in the discharge teaching?
a. Do not read without direct lighting for 6 weeks.
b. Avoid straining at stool, bending, or lifting heavy objects.
c. Irrigate conjunctiva with ophthalmic saline prior to installing antibiotic ointment.
d. Limit exposure to sunlight during the first 2 weeks when the cornea is healing. -
correct answerAvoid straining at stool, bending, or lifting heavy objects
Rationale: after cataract surgery, the client should avoid activities which increase
pressure and place strain on the suture line.
The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to
infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled, "10
mEq/5ml." how many ml of potassium chloride should the nurse add the IV fluid? (Enter
numeric value only. If is rounding is required, round to the nearest tenth.)
12.5 - correct answer12.5
Rationale: Using the formula D / H X Q: 25 mEq / 10 mEq x 5ml ꞊12.5ml
At 40 week gestation, a laboring client who is lying is a supine position tells the nurse
that she has finally found a comfortable position. What action should the nurse take?
a. Encourage the client to turn on her left side.
b. Place a pillow under the client's head and knees.
c. Explain to the client that her position is not safe.
d. Place a wedge under the client's right hip. - correct answerPlace a wedge under the
client's right hip
Rationale: Hypotension from pressure on the vena cava is a risk for the full-term client.
Placing a wedge under the right hip will relieve pressure on the vena cava. Other
options will either not relieve pressure on the vena cava or would not allow the client the
remaining her position of choice.
The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl (325
micromol/L) for discharge from the hospital. When teaching the parents about home
phototherapy, which instruction should the nurse include in the discharge teaching
plan?
,a. Reposition the infant every 2 hours.
b. Perform diaper changes under the light.
c. Feed the infant every 4 hours.
d. Cover with a receiving blanket. - correct answerReposition the infant every 2 hours.
Rational: An infant, who is receiving phototherapy for hyperbilirubinemia, should be
repositioned every two hours. The position changes ensure that the phototherapy lights
reach all of the body surface areas. Bathing, feedings, and diaper changes are ways for
the parents to bond with the infant and can occur away from the treatment. Feedings
need to occur more frequently than every 4 hours to prevent dehydration. The infant
should wear only a diaper so that the skin is exposed to the phototherapy.
A client with a history of diabetes and coronary artery disease is admitted with
shortness of breath, anxiety, and confusion. The client's blood pressure is 80/60 mmHg,
heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar
crackles. The client's average urinary output is 5 ml/hour. Normal saline is infusing at
124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump.
With intervention should the nurse implement?
a. Irrigate the indwelling urinary catheter.
b. Prepare the client for external pacing.
c. Obtain capillary blood glucose measurement.
d. Titrate the dopamine infusion to raise the BP. - correct answerTitrate the dopamine
infusion to raise the BP.
Rationale: the client is experiencing cardiogenic shock and requires titration per protocol
of the vasoactive secondary infusion, dopamine, to increase the blood pressure. Low
hourly urine output is due to shock and does not indicate a need for catheter irrigation.
Pacing is not indicated based on the client's capillary blood glucose should be
monitored but is not directly indicated at this time.
The nurse ends the assessment of a client by performing a mental status exam. Which
statement correctly describes the purpose of the mental status exam?
a. Determine the client's level of emotional functioning'
b. Assess functional ability of the primary support system.
c. Evaluate the client's mood, cognition and orientation.
d. Review the client's pattern of adaptive coping skill - correct answerEvaluate the
client's mood, cognition and orientation.
Rational: the mental status exam assesses the client for abnormalities in cognitive
functioning; potential thought processes, mood and reasoning, the other options listed
are all components of the client's psychosocial assessment.
An older adult resident of a long-term care facility has a 5-year history of hypertension.
The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood
, pressure is currently 142/89. Which interventions should the nurse implement? (Select
all that apply)
a. Administer a daily dose of lisinopril as scheduled.
b. Assess the client for postural hypotension.
c. Notify the healthcare provider immediately
d. Provide a PRN dose of acetaminophen for headache
e. Withhold the next scheduled daily dose of warfarin. - correct answera. Administer a
daily dose of lisinopril as scheduled.
d. Provide a PRN dose of acetaminophen for headache
Rational: the client' routinely scheduled medication, lisinopril, is an antihypertensive
medication and should be administered as scheduled to maintain the client's blood
pressure. A PRN dose of acetaminophen should be given for the client's headache. The
other options are not indicated for this situation.
When conducting diet teaching for a client who is on a postoperative soft diet, which
foods should eat? (Select all that apply)
a. Pasta, noodles, rice.
b. Egg, tofu, ground meat.
c. Mashed, potatoes, pudding, milk.
d. Brussel sprouts, blackberries, seeds.
e. Corn bran, whole wheat bread, whole grains. - correct answera. Pasta, noodles, rice.
b. Egg, tofu, ground meat.
c. Mashed, potatoes, pudding, milk.
Rational: a client's postoperative diet is commonly progressed as tolerated. A soft diet
includes foods that are mechanically soft in texture (pasta, egg, ground meat, potatoes,
and pudding. High fiber foods that require thorough chewing and gas forming foods,
such as cruciferous vegetables and fresh fruits with skin, grains and seeds are omitted.
When planning care for a client with acute pancreatitis, which nursing intervention has
the highest priority?
a. Withhold food and fluid intake.
b. Initiate IV fluid replacement.
c. Administer antiemetic as needed.
d. Evaluate intake and output ratio. - correct answerWithhold food and fluid intake
Rational: The pathophysiologic processes in acute pancreatitis result from oral fluid and
ingestion that causes secretion of pancreatic enzymes, which destroy ductal tissue and
pancreatic cells, resulting in auto digestion and fibrosis of the pancreas. The main focus
of the nursing care is reducing pain caused by pancreatic destruction through
Answers | Latest Update 2026 | Exam Prep
PDF | Graded A+
An adult client is exhibit the manic stage of bipolar disorder is admitted to the psychiatric
unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week
"I'm trying to start a new business and "I'm too busy to eat". The client is oriented to
time, place, person but not situation. Which nursing problem has the greatest priority?
a. Hygiene-self-care deficit
b. Imbalance nutrition
c. Disturbed sleep pattern
d. Self-neglect - correct answerImbalance nutrition
Rationale: The client's nutritional status has the highest priority at this time, and finger
foods are often provided, so the client who is on the maniac phase of bipolar disease
can receive adequate nutrition. Other options are nursing problems that should also be
addresses with the client's plan of care, but at this stage in the client's treatment,
adequate nutrition is a priority
A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks
ago returns to the clinic for a follow up visit. The client has a postoperative ejection
fraction ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal
edema, and a 5pound weight gain. Which intervention the nurse implement?
a. Arrange transport for admission to the hospital.
b. Insert saline lock for IV diuretic therapy.
c. Assess compliance with routine prescriptions.
d. Instruct the client to monitor daily caloric intake. - correct answerAssess compliance
with routine prescriptions.
Rationale: Fluid retention may be a sign that the client is not taking the medication as
prescribed or that the prescriptions may need adjustment to manage cardiac function
post-PTCA (normal ejection fraction range is 50 to 75%)
The nurse is assessing a client's nailbeds. Witch appearance indicates further follow-up
is needed for problems associated with chronic hypoxia?
Clubbing FLIP for photo!!! - correct answerclubbing
The RN is assigned to care for four surgical clients. After receiving report, which client
should the nurse see first? The client who is:
,a. Two days postoperative bladder surgery with continuous bladder irrigation infusing.
b. One day postoperative laparoscopic cholecystectomy requesting pain medication.
c. Three days postoperative colon resection receiving transfusion of packed RBCs.
d. Preoperative, in buck's traction, and scheduled for hip arthroplasty within the next 12
hours. - correct answerThree days postoperative colon resection receiving transfusion
of packed RBCs.
The nurse is preparing an older client for discharge following cataract extraction. Which
instruction should be include in the discharge teaching?
a. Do not read without direct lighting for 6 weeks.
b. Avoid straining at stool, bending, or lifting heavy objects.
c. Irrigate conjunctiva with ophthalmic saline prior to installing antibiotic ointment.
d. Limit exposure to sunlight during the first 2 weeks when the cornea is healing. -
correct answerAvoid straining at stool, bending, or lifting heavy objects
Rationale: after cataract surgery, the client should avoid activities which increase
pressure and place strain on the suture line.
The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to
infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled, "10
mEq/5ml." how many ml of potassium chloride should the nurse add the IV fluid? (Enter
numeric value only. If is rounding is required, round to the nearest tenth.)
12.5 - correct answer12.5
Rationale: Using the formula D / H X Q: 25 mEq / 10 mEq x 5ml ꞊12.5ml
At 40 week gestation, a laboring client who is lying is a supine position tells the nurse
that she has finally found a comfortable position. What action should the nurse take?
a. Encourage the client to turn on her left side.
b. Place a pillow under the client's head and knees.
c. Explain to the client that her position is not safe.
d. Place a wedge under the client's right hip. - correct answerPlace a wedge under the
client's right hip
Rationale: Hypotension from pressure on the vena cava is a risk for the full-term client.
Placing a wedge under the right hip will relieve pressure on the vena cava. Other
options will either not relieve pressure on the vena cava or would not allow the client the
remaining her position of choice.
The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl (325
micromol/L) for discharge from the hospital. When teaching the parents about home
phototherapy, which instruction should the nurse include in the discharge teaching
plan?
,a. Reposition the infant every 2 hours.
b. Perform diaper changes under the light.
c. Feed the infant every 4 hours.
d. Cover with a receiving blanket. - correct answerReposition the infant every 2 hours.
Rational: An infant, who is receiving phototherapy for hyperbilirubinemia, should be
repositioned every two hours. The position changes ensure that the phototherapy lights
reach all of the body surface areas. Bathing, feedings, and diaper changes are ways for
the parents to bond with the infant and can occur away from the treatment. Feedings
need to occur more frequently than every 4 hours to prevent dehydration. The infant
should wear only a diaper so that the skin is exposed to the phototherapy.
A client with a history of diabetes and coronary artery disease is admitted with
shortness of breath, anxiety, and confusion. The client's blood pressure is 80/60 mmHg,
heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar
crackles. The client's average urinary output is 5 ml/hour. Normal saline is infusing at
124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump.
With intervention should the nurse implement?
a. Irrigate the indwelling urinary catheter.
b. Prepare the client for external pacing.
c. Obtain capillary blood glucose measurement.
d. Titrate the dopamine infusion to raise the BP. - correct answerTitrate the dopamine
infusion to raise the BP.
Rationale: the client is experiencing cardiogenic shock and requires titration per protocol
of the vasoactive secondary infusion, dopamine, to increase the blood pressure. Low
hourly urine output is due to shock and does not indicate a need for catheter irrigation.
Pacing is not indicated based on the client's capillary blood glucose should be
monitored but is not directly indicated at this time.
The nurse ends the assessment of a client by performing a mental status exam. Which
statement correctly describes the purpose of the mental status exam?
a. Determine the client's level of emotional functioning'
b. Assess functional ability of the primary support system.
c. Evaluate the client's mood, cognition and orientation.
d. Review the client's pattern of adaptive coping skill - correct answerEvaluate the
client's mood, cognition and orientation.
Rational: the mental status exam assesses the client for abnormalities in cognitive
functioning; potential thought processes, mood and reasoning, the other options listed
are all components of the client's psychosocial assessment.
An older adult resident of a long-term care facility has a 5-year history of hypertension.
The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood
, pressure is currently 142/89. Which interventions should the nurse implement? (Select
all that apply)
a. Administer a daily dose of lisinopril as scheduled.
b. Assess the client for postural hypotension.
c. Notify the healthcare provider immediately
d. Provide a PRN dose of acetaminophen for headache
e. Withhold the next scheduled daily dose of warfarin. - correct answera. Administer a
daily dose of lisinopril as scheduled.
d. Provide a PRN dose of acetaminophen for headache
Rational: the client' routinely scheduled medication, lisinopril, is an antihypertensive
medication and should be administered as scheduled to maintain the client's blood
pressure. A PRN dose of acetaminophen should be given for the client's headache. The
other options are not indicated for this situation.
When conducting diet teaching for a client who is on a postoperative soft diet, which
foods should eat? (Select all that apply)
a. Pasta, noodles, rice.
b. Egg, tofu, ground meat.
c. Mashed, potatoes, pudding, milk.
d. Brussel sprouts, blackberries, seeds.
e. Corn bran, whole wheat bread, whole grains. - correct answera. Pasta, noodles, rice.
b. Egg, tofu, ground meat.
c. Mashed, potatoes, pudding, milk.
Rational: a client's postoperative diet is commonly progressed as tolerated. A soft diet
includes foods that are mechanically soft in texture (pasta, egg, ground meat, potatoes,
and pudding. High fiber foods that require thorough chewing and gas forming foods,
such as cruciferous vegetables and fresh fruits with skin, grains and seeds are omitted.
When planning care for a client with acute pancreatitis, which nursing intervention has
the highest priority?
a. Withhold food and fluid intake.
b. Initiate IV fluid replacement.
c. Administer antiemetic as needed.
d. Evaluate intake and output ratio. - correct answerWithhold food and fluid intake
Rational: The pathophysiologic processes in acute pancreatitis result from oral fluid and
ingestion that causes secretion of pancreatic enzymes, which destroy ductal tissue and
pancreatic cells, resulting in auto digestion and fibrosis of the pancreas. The main focus
of the nursing care is reducing pain caused by pancreatic destruction through
