[HESI RN EXIT EXAM] QUESTIONS AND ANSWERS ALREADY GRADED
A+. 100% VERIFIED SOLUTIONS | UPDATED PER LATEST GUIDELINES |
GRADED A+
Question 1
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following
actions should the nurse take to prevent deep vein thrombosis?
A. Encourage the client to perform ankle pumps every 2 hours
B. Place a pillow under the client's knees
C. Massage the client's lower extremities
D. Apply cold packs to the surgical site
🟢 Correct Answer: A. Encourage the client to perform ankle pumps every 2 hours
🔴 RATIONALE: Ankle pumps promote venous return and help prevent deep vein thrombosis. Placing a pillow
under the knees can impede venous return, massage is contraindicated due to risk of clot dislodgement, and
cold packs do not prevent DVT.
,Question 2
A nurse is assessing a client who has a new diagnosis of heart failure. Which of the following findings should the
nurse expect?
A. Decreased jugular venous pressure
B. Peripheral edema
C. Increased urine output
D. Orthopnea
🟢 Correct Answer: D. Orthopnea
🔴 RATIONALE: Orthopnea (difficulty breathing when lying flat) is a common finding in heart failure due to
pulmonary congestion. Jugular venous pressure is typically elevated, peripheral edema is present but orthopnea
is a classic symptom, and urine output is typically decreased.
Question 3
A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the
nurse take first?
A. Obtain a signed consent form
,B. Verify the client's identification
C. Assess the client's vital signs
D. Initiate a 20-gauge IV line
🟢 Correct Answer: A. Obtain a signed consent form
🔴 RATIONALE: A signed consent form must be obtained before initiating a blood transfusion. While verifying
identification, assessing vital signs, and initiating an IV are important, obtaining consent is the priority and must
be done before the procedure.
Question 4
A nurse is caring for a client who has a nasogastric (NG) tube to low intermittent suction. Which of the following
actions should the nurse take to maintain tube patency?
A. Flush the tube with 30 mL of air every 4 hours
B. Irrigate the tube with sterile water as prescribed
C. Clamp the tube for 15 minutes every hour
D. Apply petroleum jelly to the nares
🟢 Correct Answer: B. Irrigate the tube with sterile water as prescribed
, 🔴 RATIONALE: Irrigating the NG tube with sterile water or normal saline as prescribed helps maintain patency.
Flushing with air is not recommended, clamping does not maintain patency, and petroleum jelly is used to
prevent skin breakdown, not patency.
Question 5
A nurse is assessing a client who is 2 hours postoperative following a thyroidectomy. Which of the following
findings should the nurse report immediately?
A. Pain at the incision site
B. Hoarseness
C. Stridor
D. Difficulty swallowing
🟢 Correct Answer: C. Stridor
🔴 RATIONALE: Stridor indicates laryngeal edema and airway obstruction, which is a life-threatening
emergency following thyroidectomy. Pain, hoarseness, and difficulty swallowing are expected findings but
should be monitored; stridor requires immediate intervention.
A+. 100% VERIFIED SOLUTIONS | UPDATED PER LATEST GUIDELINES |
GRADED A+
Question 1
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following
actions should the nurse take to prevent deep vein thrombosis?
A. Encourage the client to perform ankle pumps every 2 hours
B. Place a pillow under the client's knees
C. Massage the client's lower extremities
D. Apply cold packs to the surgical site
🟢 Correct Answer: A. Encourage the client to perform ankle pumps every 2 hours
🔴 RATIONALE: Ankle pumps promote venous return and help prevent deep vein thrombosis. Placing a pillow
under the knees can impede venous return, massage is contraindicated due to risk of clot dislodgement, and
cold packs do not prevent DVT.
,Question 2
A nurse is assessing a client who has a new diagnosis of heart failure. Which of the following findings should the
nurse expect?
A. Decreased jugular venous pressure
B. Peripheral edema
C. Increased urine output
D. Orthopnea
🟢 Correct Answer: D. Orthopnea
🔴 RATIONALE: Orthopnea (difficulty breathing when lying flat) is a common finding in heart failure due to
pulmonary congestion. Jugular venous pressure is typically elevated, peripheral edema is present but orthopnea
is a classic symptom, and urine output is typically decreased.
Question 3
A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the
nurse take first?
A. Obtain a signed consent form
,B. Verify the client's identification
C. Assess the client's vital signs
D. Initiate a 20-gauge IV line
🟢 Correct Answer: A. Obtain a signed consent form
🔴 RATIONALE: A signed consent form must be obtained before initiating a blood transfusion. While verifying
identification, assessing vital signs, and initiating an IV are important, obtaining consent is the priority and must
be done before the procedure.
Question 4
A nurse is caring for a client who has a nasogastric (NG) tube to low intermittent suction. Which of the following
actions should the nurse take to maintain tube patency?
A. Flush the tube with 30 mL of air every 4 hours
B. Irrigate the tube with sterile water as prescribed
C. Clamp the tube for 15 minutes every hour
D. Apply petroleum jelly to the nares
🟢 Correct Answer: B. Irrigate the tube with sterile water as prescribed
, 🔴 RATIONALE: Irrigating the NG tube with sterile water or normal saline as prescribed helps maintain patency.
Flushing with air is not recommended, clamping does not maintain patency, and petroleum jelly is used to
prevent skin breakdown, not patency.
Question 5
A nurse is assessing a client who is 2 hours postoperative following a thyroidectomy. Which of the following
findings should the nurse report immediately?
A. Pain at the incision site
B. Hoarseness
C. Stridor
D. Difficulty swallowing
🟢 Correct Answer: C. Stridor
🔴 RATIONALE: Stridor indicates laryngeal edema and airway obstruction, which is a life-threatening
emergency following thyroidectomy. Pain, hoarseness, and difficulty swallowing are expected findings but
should be monitored; stridor requires immediate intervention.
