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Exam (elaborations)

HESI EXIT EXAM QUESTIONS & ANSWERS.

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HESI EXIT EXAM QUESTIONS & ANSWERS.

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HESI EXIT EXAM QUESTIONS
& ANSWERS.
1. A nurse is evaluating care of an immobilized patient. Which action will the nurse take?

a. Focus on whether the interdisciplinary team is satisfied with the care.
Compare the patient’s actual outcomes with the outcomes in the care

b. plan.
Involve primarily the patient’s family and health care team to
c. determine goal achievement.
Use objective data solely in determining whether interventions have
d. been successful.
ANS: B
From your perspective as the nurse, you are to evaluate outcomes and
response to nursing care and compare the patient’s actual outcomes with the outcomes
selected during planning. Ask if the patient’s expectations (subjective data) of care are
being met, and use objective data to determine the success of interventions. Just as it was
important to include the patient during the assessment and planning phase of the care plan,
it is essential to have the patient’s evaluation of the plan of care, not just the patient’s
family and health care team.

2. A nurse is supervising the logrolling of a patient. To which patient is the nurse
most likely providing care?




a. A patient with neck surgery

b. A patient with hypostatic pneumonia


c. A patient with a total knee replacement

d. A patient with a Stage IV pressure ulcer


ANS: A
A nurse supervises and aids personnel when there is a health care provider’s

, HESI EXIT EXAM QUESTIONS
& ANSWERS.
order to logroll a patient. Patients who have suffered from spinal cord injury or are
recovering from neck, back, or spinal surgery often need to keep the spinal column in straight
alignment to prevent further injury. Hypostatic pneumonia, total knee replacement, and Stage
IV ulcers do not have to be logrolled.

3. The nurse is providing teaching to an immobilized patient with


impaired skin integrity about diet. Which diet will the nurse recommend?

a. High protein, high calorie


b. High carbohydrate, low fat

c. High vitamin A, high vitamin E

d. Fluid restricted, bland




ANS: A

Because the body needs protein to repair injured tissue and rebuild depleted protein stores,
give the immobilized patient a high-protein, high-calorie diet. A high-carbohydrate, low-
fat diet is not beneficial for an immobilized patient. Vitamins B and C are needed rather
than A and E. Fluid restriction can be detrimental to the immobilized patient; this can lead
to dehydration. A bland diet is not necessary for immobilized patients.

4. The nurse is caring for a patient who has had a stroke causing total paralysis of
the right side. To help maintain joint function and minimize




the disability from contractures, passive ROM will be initiated. When should the
nurse begin this therapy?

a. After the acute phase of the disease has passed


b. As soon as the ability to move is lost

c. Once the patient enters the rehab unit

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