HESI TEST BANK/ HESI EXIT EXAM TEST BANK NEWEST
2024-2025 COMPLETE ACTUAL EXAM TESTBANK
APPROVED QUESTIONS AND WELL ELABORATED
ANSWERS WITH RATIONALES (CORRECT VERIFIED
ANSWERS) LATEST UPDATED VERSION 2024 |ALREADY
GRADED A+ (BRAND NEW!!)
While assessing a radial artery catheter, the client complains of
numbness and pain distal to the insertion site. What
interventions should the nurse implement? - Answer-Promptly
remove the arterial catheter from the radial artery.
A client is admitted with an epidural hematoma that resulted
from a skateboarding accident. To differentiate the vascular
source of the intracranial bleeding, which finding should the
nurse monitor? - Answer-Rapid onset of decreased level of
consciousness.
When preparing a client for discharge from the hospital
following a cystectomy and a urinary diversion to treat bladder
cancer, which instruction is most important for the nurse to
include in the client's discharge teaching plan? - Answer-Report
any signs of cloudy urine output.
,After repositioning an immobile client, the nurse observes an
area of hyperemia. To assess for blanching, what action should
the nurse take? - Answer-Apply light pressure over the area.
The nurse enters a client's room and observes the client's wrist
restraint secured as seen in the picture. What action should the
nurse take? - Answer-Reposition the restraint tie onto the
bedframe.
A female client with acute respiratory distress syndrome (ARDS)
is chemically paralyzed and sedated while she is on as assist-
control ventilator using 50% FIO2. Which assessment finding
warrants immediate intervention by the nurse? - Answer-
Diminished left lower lobe sounds
Rationale: Diminished lobe sounds indicate collapsed alveoli or
tension pneumothorax, which required immediate chest tube
insertion to re-inflate the lung.
A client who sustained a head injury following an automobile
collision is admitted to the hospital. The nurse include the
client's risk for developing increased intracranial pressure (ICP)
in the plan of care. Which signs indicate to the nurse that ICP
has increased? - Answer-Increased Glasgow coma scale score.
Nuchal rigidity and papilledema.
,Confusion and papilledema
Periorbital ecchymosis.
Rationale: papilledema is always an indicator of increased ICP,
and confusion is usually the first sign of
increased ICP. Other options do not necessarily reflect
increased ICP.
The nurse is caring for a client receiving continuous IV fluids
through a single lumen central venous catheter (CVC). Based on
the CVC care bundle, which action should be completed daily to
reduce the risk for infection? - Answer-Confirm the necessity
for continued use of the CVC.
During an annual physical examination, an older woman's
fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8
mmol/L (SI). Which additional finding obtained during a follow-
up visit 2 weeks later is most indicative that the client has
diabetes mellitus (DM)? - Answer-Repeated fasting blood sugar
(FBS) is 132 mg/dl or 7.4 mmol/L (SI).
A client who was admitted yesterday with severe dehydration is
complaining of pain a 24 gauge IV with normal saline is infusing
, at a rate of 150 ml/hour. Which intervention should the nurse
implement first? - Answer-Stop the normal saline infusion.
An elderly female is admitted because of a change in her level
of sensorium. During the evening shift, the client attempts to
get out bed and falls, breaking her left hip. Buck's skin traction
is applied to the left leg while waiting for surgery. Which
intervention is most important for the nurse to include in this
client's plan care? - Answer-Ensure proper alignment of the leg
in traction.
A client who had a right hip replacement 3 day ago is pale has
diminished breath sound over the left lower lung fields, a
temperature of 100.2 F, and an oxygen saturation rate of 90%.
The client is scheduled to be transferred to a skilled nursing
facility (SNF) tomorrow for rehabilitative critical pathway.
Based on the client's symptoms, what recommendation should
the nurse give the healthcare provider? - Answer-Reassess
readiness for SNF transfer.
A client who is newly diagnosed with type 2 diabetes mellitus
(DM) receives a prescription for metformin (Glucophage) 500
mg PO twice daily. What information should the nurse include
in this client's teaching plan? (Select all that apply.) - Answer-
Recognize signs and symptoms of hypoglycemia.
2024-2025 COMPLETE ACTUAL EXAM TESTBANK
APPROVED QUESTIONS AND WELL ELABORATED
ANSWERS WITH RATIONALES (CORRECT VERIFIED
ANSWERS) LATEST UPDATED VERSION 2024 |ALREADY
GRADED A+ (BRAND NEW!!)
While assessing a radial artery catheter, the client complains of
numbness and pain distal to the insertion site. What
interventions should the nurse implement? - Answer-Promptly
remove the arterial catheter from the radial artery.
A client is admitted with an epidural hematoma that resulted
from a skateboarding accident. To differentiate the vascular
source of the intracranial bleeding, which finding should the
nurse monitor? - Answer-Rapid onset of decreased level of
consciousness.
When preparing a client for discharge from the hospital
following a cystectomy and a urinary diversion to treat bladder
cancer, which instruction is most important for the nurse to
include in the client's discharge teaching plan? - Answer-Report
any signs of cloudy urine output.
,After repositioning an immobile client, the nurse observes an
area of hyperemia. To assess for blanching, what action should
the nurse take? - Answer-Apply light pressure over the area.
The nurse enters a client's room and observes the client's wrist
restraint secured as seen in the picture. What action should the
nurse take? - Answer-Reposition the restraint tie onto the
bedframe.
A female client with acute respiratory distress syndrome (ARDS)
is chemically paralyzed and sedated while she is on as assist-
control ventilator using 50% FIO2. Which assessment finding
warrants immediate intervention by the nurse? - Answer-
Diminished left lower lobe sounds
Rationale: Diminished lobe sounds indicate collapsed alveoli or
tension pneumothorax, which required immediate chest tube
insertion to re-inflate the lung.
A client who sustained a head injury following an automobile
collision is admitted to the hospital. The nurse include the
client's risk for developing increased intracranial pressure (ICP)
in the plan of care. Which signs indicate to the nurse that ICP
has increased? - Answer-Increased Glasgow coma scale score.
Nuchal rigidity and papilledema.
,Confusion and papilledema
Periorbital ecchymosis.
Rationale: papilledema is always an indicator of increased ICP,
and confusion is usually the first sign of
increased ICP. Other options do not necessarily reflect
increased ICP.
The nurse is caring for a client receiving continuous IV fluids
through a single lumen central venous catheter (CVC). Based on
the CVC care bundle, which action should be completed daily to
reduce the risk for infection? - Answer-Confirm the necessity
for continued use of the CVC.
During an annual physical examination, an older woman's
fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8
mmol/L (SI). Which additional finding obtained during a follow-
up visit 2 weeks later is most indicative that the client has
diabetes mellitus (DM)? - Answer-Repeated fasting blood sugar
(FBS) is 132 mg/dl or 7.4 mmol/L (SI).
A client who was admitted yesterday with severe dehydration is
complaining of pain a 24 gauge IV with normal saline is infusing
, at a rate of 150 ml/hour. Which intervention should the nurse
implement first? - Answer-Stop the normal saline infusion.
An elderly female is admitted because of a change in her level
of sensorium. During the evening shift, the client attempts to
get out bed and falls, breaking her left hip. Buck's skin traction
is applied to the left leg while waiting for surgery. Which
intervention is most important for the nurse to include in this
client's plan care? - Answer-Ensure proper alignment of the leg
in traction.
A client who had a right hip replacement 3 day ago is pale has
diminished breath sound over the left lower lung fields, a
temperature of 100.2 F, and an oxygen saturation rate of 90%.
The client is scheduled to be transferred to a skilled nursing
facility (SNF) tomorrow for rehabilitative critical pathway.
Based on the client's symptoms, what recommendation should
the nurse give the healthcare provider? - Answer-Reassess
readiness for SNF transfer.
A client who is newly diagnosed with type 2 diabetes mellitus
(DM) receives a prescription for metformin (Glucophage) 500
mg PO twice daily. What information should the nurse include
in this client's teaching plan? (Select all that apply.) - Answer-
Recognize signs and symptoms of hypoglycemia.
