HESI EXIT
EXAM
High-Yield Qs & Answers with Rationale
This Exam Description:
High-Yield Qs
Answers with Rationale
Multiple Choices
100% Guaranteed Pass
,The nurse has completed giving discharge instructions to a client who has had a
total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse
determines that the client understands the instructions if the client makes which
statement?
1."Changes in the shape of the knee are expected."
2."Fever, redness, and increased pain are expected."
3."All caregivers should be told about the metal implant."
4."Bleeding gums or black stools may occur, but this is normal." - CORRECT
ANSWER -3
A TJR is also known as a total joint arthroplasty (TJA). The client must inform
other caregivers of the presence of the metal implant because certain tests and
procedures will need to be avoided. After total knee replacement, the client should
report signs and symptoms of infection and any changes in the shape of the knee.
These could indicate developing complications. With a metal implant, the client
may be on anticoagulant therapy and should report adverse effects of this therapy,
including bleeding from a variety of sources, and the client will need antibiotic
prophylaxis for invasive procedures.
The nurse is caring for a client after the application of a plaster cast for a fractured
left radius. The nurse should suspect impairment with the neurovascular status of
the client's casted extremity if which findings are noted? Select all that apply.
1.Capillary refill is less than 3 seconds 2.Pulses present and with swollen, pink
fingers
3.Client report of severe, deep, unrelenting pain
4.Client report of pain as nurse assesses finger movement
5.Client report of numbness and tingling sensation in the fingers - CORRECT
ANSWER -3, 4, 5
The pressure in compartment syndrome, if unrelieved, will cause permanent
damage to nerve and muscle tissue distal to the pressure. Circulatory damage may
result in necrosis. Nerve and muscle damage may result in permanent
contractures, deformity of the extremity, and functional impairment. Normal
capillary refill time is 3 seconds or less. Pink appearance and a pulse indicate
adequate blood flow; swelling is expected after a fracture. Client report of severe,
deep, unrelenting pain; client report of numbness and tingling sensation; and client
report of pain as the nurse assesses finger movement are indicative of development
of compartment syndrome.
,A client with a 4-day-old lumbar vertebral fracture is experiencing muscle
spasms. Which are interventions to aid the client in relieving the spasm?
Select all that apply. 1.Ice
2.Heat
3.Analgesics
4.Muscle relaxers
5.Intermittent traction - CORRECT ANSWER -2, 3, 4, 5
Heat, analgesics, muscle relaxers, and traction all may be used to relieve the pain
of muscle spasm in the client with a vertebral fracture. Ice is applied to a painful
site only for the first 48 to 72 hours (depending on the health care provider's
preference) after an injury. Application of ice to the spine of a client could be
uncomfortable and could result in feelings of being chilled.
The nurse is caring for a client who had surgery to repair a fractured left-sided hip
using a posterior approach. In implementing hip precautions, which action should
the nurse teach the client to avoid?
1.Crossing legs at the ankle
2.Using an elevated toilet seat 3.Placing a pillow between the legs 4.Keeping the
legs abducted from the midline - CORRECT ANSWER -1
Following surgery to repair a fractured hip using a posterior approach, client
education should include the following: avoiding crossing the legs at the ankle or
the knee, using an elevated toilet seat, placing a pillow between the legs while lying
down for the first 6 weeks, keeping the legs abducted from the midline, and keeping
the hip in a neutral position at all times.
An older client is diagnosed with osteoporosis. The nurse teaches the client about
self-care measures, knowing that the client is most at risk for which problem as a
result of this disorder of the bones? 1.Anemia
2.Fractures
3.Infection
4.Muscle sprains - CORRECT ANSWER -2
The client is most at risk for fractures as a result of osteoporosis. Although other
complications can occur, fracture is the greatest concern. Anemia and infection can
occur with bone marrow disorders, and muscle sprains are unrelated to
osteoporosis.
, A client with a new medication prescription for allopurinol asks the nurse, "I know
this is for gout, but how does it work?" The nurse plans to reply based on which
medication action?
1.Allopurinol decreases uric acid production.
2.Allopurinol reduces the production of fibrinogen.
3.Allopurinol decreases the risk of sulfa crystal formation in the urine.
4.Allopurinol prevents influx of calcium ions during cell depolarization. - CORRECT
ANSWER -1
Allopurinol is classified as an antigout medication. It decreases uric acid
production by inhibiting the xanthine oxidase enzyme, and it reduces uric acid
concentrations in both serum and urine. The other options are incorrect.
The nurse is caring for a client diagnosed with osteitis deformans (Paget's disease).
Which does the nurse identify as the cause of the client's stooped posture and
bowing of lower extremities?
1.Muscle metabolism and growth 2.Bone resorption and regeneration 3.Nervous
system impulse transmission 4.Joint integrity and synovial fluid production -
CORRECT ANSWER -2
Paget's disease is characterized by skeletal deformities resulting from abnormal
bone resorption followed by abnormal regeneration. It is not caused by problems
with muscle, nervous system, or joint functioning.
A client has been diagnosed with gout, and the nurse provides dietary instructions.
The nurse determines that the client needs additional teaching if the client states
that it is acceptable to eat which food?
1.Carrots
2.Tapioca
3.Chocolate
4.Chicken liver - CORRECT ANSWER -4
Liver and other organ meats should be omitted from the diet of a client who has
gout because of their high purine content. Purines are a form of protein. The food
items identified in the other options contain negligible amounts of purines and may
be consumed freely by the client with gout.
EXAM
High-Yield Qs & Answers with Rationale
This Exam Description:
High-Yield Qs
Answers with Rationale
Multiple Choices
100% Guaranteed Pass
,The nurse has completed giving discharge instructions to a client who has had a
total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse
determines that the client understands the instructions if the client makes which
statement?
1."Changes in the shape of the knee are expected."
2."Fever, redness, and increased pain are expected."
3."All caregivers should be told about the metal implant."
4."Bleeding gums or black stools may occur, but this is normal." - CORRECT
ANSWER -3
A TJR is also known as a total joint arthroplasty (TJA). The client must inform
other caregivers of the presence of the metal implant because certain tests and
procedures will need to be avoided. After total knee replacement, the client should
report signs and symptoms of infection and any changes in the shape of the knee.
These could indicate developing complications. With a metal implant, the client
may be on anticoagulant therapy and should report adverse effects of this therapy,
including bleeding from a variety of sources, and the client will need antibiotic
prophylaxis for invasive procedures.
The nurse is caring for a client after the application of a plaster cast for a fractured
left radius. The nurse should suspect impairment with the neurovascular status of
the client's casted extremity if which findings are noted? Select all that apply.
1.Capillary refill is less than 3 seconds 2.Pulses present and with swollen, pink
fingers
3.Client report of severe, deep, unrelenting pain
4.Client report of pain as nurse assesses finger movement
5.Client report of numbness and tingling sensation in the fingers - CORRECT
ANSWER -3, 4, 5
The pressure in compartment syndrome, if unrelieved, will cause permanent
damage to nerve and muscle tissue distal to the pressure. Circulatory damage may
result in necrosis. Nerve and muscle damage may result in permanent
contractures, deformity of the extremity, and functional impairment. Normal
capillary refill time is 3 seconds or less. Pink appearance and a pulse indicate
adequate blood flow; swelling is expected after a fracture. Client report of severe,
deep, unrelenting pain; client report of numbness and tingling sensation; and client
report of pain as the nurse assesses finger movement are indicative of development
of compartment syndrome.
,A client with a 4-day-old lumbar vertebral fracture is experiencing muscle
spasms. Which are interventions to aid the client in relieving the spasm?
Select all that apply. 1.Ice
2.Heat
3.Analgesics
4.Muscle relaxers
5.Intermittent traction - CORRECT ANSWER -2, 3, 4, 5
Heat, analgesics, muscle relaxers, and traction all may be used to relieve the pain
of muscle spasm in the client with a vertebral fracture. Ice is applied to a painful
site only for the first 48 to 72 hours (depending on the health care provider's
preference) after an injury. Application of ice to the spine of a client could be
uncomfortable and could result in feelings of being chilled.
The nurse is caring for a client who had surgery to repair a fractured left-sided hip
using a posterior approach. In implementing hip precautions, which action should
the nurse teach the client to avoid?
1.Crossing legs at the ankle
2.Using an elevated toilet seat 3.Placing a pillow between the legs 4.Keeping the
legs abducted from the midline - CORRECT ANSWER -1
Following surgery to repair a fractured hip using a posterior approach, client
education should include the following: avoiding crossing the legs at the ankle or
the knee, using an elevated toilet seat, placing a pillow between the legs while lying
down for the first 6 weeks, keeping the legs abducted from the midline, and keeping
the hip in a neutral position at all times.
An older client is diagnosed with osteoporosis. The nurse teaches the client about
self-care measures, knowing that the client is most at risk for which problem as a
result of this disorder of the bones? 1.Anemia
2.Fractures
3.Infection
4.Muscle sprains - CORRECT ANSWER -2
The client is most at risk for fractures as a result of osteoporosis. Although other
complications can occur, fracture is the greatest concern. Anemia and infection can
occur with bone marrow disorders, and muscle sprains are unrelated to
osteoporosis.
, A client with a new medication prescription for allopurinol asks the nurse, "I know
this is for gout, but how does it work?" The nurse plans to reply based on which
medication action?
1.Allopurinol decreases uric acid production.
2.Allopurinol reduces the production of fibrinogen.
3.Allopurinol decreases the risk of sulfa crystal formation in the urine.
4.Allopurinol prevents influx of calcium ions during cell depolarization. - CORRECT
ANSWER -1
Allopurinol is classified as an antigout medication. It decreases uric acid
production by inhibiting the xanthine oxidase enzyme, and it reduces uric acid
concentrations in both serum and urine. The other options are incorrect.
The nurse is caring for a client diagnosed with osteitis deformans (Paget's disease).
Which does the nurse identify as the cause of the client's stooped posture and
bowing of lower extremities?
1.Muscle metabolism and growth 2.Bone resorption and regeneration 3.Nervous
system impulse transmission 4.Joint integrity and synovial fluid production -
CORRECT ANSWER -2
Paget's disease is characterized by skeletal deformities resulting from abnormal
bone resorption followed by abnormal regeneration. It is not caused by problems
with muscle, nervous system, or joint functioning.
A client has been diagnosed with gout, and the nurse provides dietary instructions.
The nurse determines that the client needs additional teaching if the client states
that it is acceptable to eat which food?
1.Carrots
2.Tapioca
3.Chocolate
4.Chicken liver - CORRECT ANSWER -4
Liver and other organ meats should be omitted from the diet of a client who has
gout because of their high purine content. Purines are a form of protein. The food
items identified in the other options contain negligible amounts of purines and may
be consumed freely by the client with gout.
