HESI EXIT EXAM REVIEW LATEST
2024 ACTUAL EAXM COMPLETE 400
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY
GRADED A+
1. The home health nurse visits an elderly female client
who had a brain attack three months ago and is now able to
ambulate with the assistance of a quad cane. Which
assessment finding has the greatest implications for this
client's care?
• The husband, who is the caregiver, begins to weep when
the nurse asks how he is doing.
• The client tells the nurse that she does not have much of an
appetite today.
• The nurse notes that there are numerous scatter
rugs throughout the house.
• The client's pulse rate is 10 beats higher than it was at the
last visit one week ago. - ...ANSWER...Ans 3 - The nurse
notes that there are numerous scatter rugs throughout the
house.
Rationale -
Scatter rugs (C) pose a safety hazard because the client can
trip on them when ambulating, so this finding has the greatest
significance in planning this client's care. Psychological
support of the caregiver (A) is a less acute need than that of
client safety. The nurse needs to obtain more information
about (B), but this is not a safety issue. (D) is not a significant
,increase, and additional assessment might provide information
about the reason for the increase (anxiety, exercise, etc.).
2. The nurse is digitally removing a fecal impaction for
a client. The nurse should stop the procedure and take
corrective action if which client reaction is noted?
• Temperature increases from 98.8° to 99.0° F.
• Pulse rate decreases from 78 to 52 beats/min. Correct
• Respiratory rate increases from 16 to 24 breaths/min.
• Blood pressure increases from 110/84 to 118/88 mm/Hg. -
...ANSWER...• Pulse rate decreases from 78 to 52 beats/min.
Rationale -
Parasympathetic reaction can occur as a result of digital
stimulation of the anal sphincter, which should be stopped if
the client experiences a vagal response, such as bradycardia
(B). (A, C, and D) do not warrant stopping the procedure.
3. The nurse is providing passive range of motion (ROM)
exercises to the hip and knee for a client who is
unconscious. After supporting the client's knee with one
hand, what action should the nurse take next?
• Raise the bed to a comfortable working level.
• Bend the client's knee.
• Move the knee toward the chest as far as it will go.
• Cradle the client's heel. Correct - ...ANSWER...•Ans -
Cradle the client's heel. Correct
RATIONALE: Passive ROM exercise for the hip and knee is
provided by supporting the joints of the knee and ankle (D)
and gently moving the limb in a slow, smooth, firm but gentle
manner. (A) should be done before the exercises are begun to
prevent injury to the nurse and client. (B) is carried out after
both joints are supported. After the knee is bent, then the
knee
,is moved toward the chest to the point of resistance (C) two or
three times.
4. A client who has moderate, persistent, chronic
neuropathic pain due to diabetic neuropathy takes
gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily.
If Step 2 of the World Health Organization (WHO) pain
relief ladder is prescribed, which drug protocol should be
implemented?
• Continue gabapentin. Correct
• Discontinue ibuprofen.
• Add aspirin to the protocol.
RATIONALE: Add oral methadone to the protocol -
...ANSWER...Ans 1 - Continue gabapentin
Based on the WHO pain relief ladder, adjunct medications,
such as gabapentin (Neurontin), an anti-seizure medication,
may be used at any step for anxiety and pain management,
so (A) should be implemented. Non-opioid analgesics, such
as ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and
3 include opioid narcotics (D), and to maintain freedom from
pain, drugs should be given around the clock rather than by
the client s PRN requests.
5. The nurse is preparing to irrigate a client's indwelling
urinary catheter using an open technique. What action should
the nurse take after applying gloves?
• Empty the client's urinary drainage bag.
• Draw up the irrigating solution into the syringe.
• Secure the client's catheter to the drainage tubing.
• Use aseptic technique to instill the irrigating solution. -
...ANSWER...ANS - Draw up the irrigating solution into the
syringe.
RATIONALE: To irrigate an indwelling urinary catheter, the
nurse should first apply gloves, then draw up the irrigating
, solution into the syringe (B). The syringe is then attached to
the catheter and the fluid instilled, using aseptic technique
(D). Once the irrigating solution is instilled, the client's
catheter should be secured to the drainage tubing (C). The
urinary drainage bag can be emptied (A) whenever intake and
output measurement is indicated, and the instilled irrigating
fluid can be subtracted from the output at that time.
6. Which client care requires the nurse to wear barrier
gloves as required by the protocol for Standard Precautions?
• Removing the empty food tray from a client with a
urinary catheter.
• Washing and combing the hair of a client with a
fractured leg in traction.
• Administering oral medications to a cooperative client with
a wound infection.
• Emptying the urinary catheter drainage bag for a client with
Alzheimer's disease. Correct - ...ANSWER...ANS - Emptying
the urinary catheter drainage bag for a client with Alzheimer's
disease.
Rationale -
possible contact with body secretions, excretions, or broken
skin is an indication for wearing barrier (nonsterile) gloves.
Emptying a urine drainage bag requires the use of gloves (D).
(A, B, and C) do not require gloves.
7. What action should the nurse implement to prevent
the formation of a sacral ulcer for a client who is
immobile?
• Maintain in a lateral position using protective wrist and
vest devices.
• Position prone with a small pillow below the diaphragm.
• Raise the head and knee gatch when lying in a supine
position.
2024 ACTUAL EAXM COMPLETE 400
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY
GRADED A+
1. The home health nurse visits an elderly female client
who had a brain attack three months ago and is now able to
ambulate with the assistance of a quad cane. Which
assessment finding has the greatest implications for this
client's care?
• The husband, who is the caregiver, begins to weep when
the nurse asks how he is doing.
• The client tells the nurse that she does not have much of an
appetite today.
• The nurse notes that there are numerous scatter
rugs throughout the house.
• The client's pulse rate is 10 beats higher than it was at the
last visit one week ago. - ...ANSWER...Ans 3 - The nurse
notes that there are numerous scatter rugs throughout the
house.
Rationale -
Scatter rugs (C) pose a safety hazard because the client can
trip on them when ambulating, so this finding has the greatest
significance in planning this client's care. Psychological
support of the caregiver (A) is a less acute need than that of
client safety. The nurse needs to obtain more information
about (B), but this is not a safety issue. (D) is not a significant
,increase, and additional assessment might provide information
about the reason for the increase (anxiety, exercise, etc.).
2. The nurse is digitally removing a fecal impaction for
a client. The nurse should stop the procedure and take
corrective action if which client reaction is noted?
• Temperature increases from 98.8° to 99.0° F.
• Pulse rate decreases from 78 to 52 beats/min. Correct
• Respiratory rate increases from 16 to 24 breaths/min.
• Blood pressure increases from 110/84 to 118/88 mm/Hg. -
...ANSWER...• Pulse rate decreases from 78 to 52 beats/min.
Rationale -
Parasympathetic reaction can occur as a result of digital
stimulation of the anal sphincter, which should be stopped if
the client experiences a vagal response, such as bradycardia
(B). (A, C, and D) do not warrant stopping the procedure.
3. The nurse is providing passive range of motion (ROM)
exercises to the hip and knee for a client who is
unconscious. After supporting the client's knee with one
hand, what action should the nurse take next?
• Raise the bed to a comfortable working level.
• Bend the client's knee.
• Move the knee toward the chest as far as it will go.
• Cradle the client's heel. Correct - ...ANSWER...•Ans -
Cradle the client's heel. Correct
RATIONALE: Passive ROM exercise for the hip and knee is
provided by supporting the joints of the knee and ankle (D)
and gently moving the limb in a slow, smooth, firm but gentle
manner. (A) should be done before the exercises are begun to
prevent injury to the nurse and client. (B) is carried out after
both joints are supported. After the knee is bent, then the
knee
,is moved toward the chest to the point of resistance (C) two or
three times.
4. A client who has moderate, persistent, chronic
neuropathic pain due to diabetic neuropathy takes
gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily.
If Step 2 of the World Health Organization (WHO) pain
relief ladder is prescribed, which drug protocol should be
implemented?
• Continue gabapentin. Correct
• Discontinue ibuprofen.
• Add aspirin to the protocol.
RATIONALE: Add oral methadone to the protocol -
...ANSWER...Ans 1 - Continue gabapentin
Based on the WHO pain relief ladder, adjunct medications,
such as gabapentin (Neurontin), an anti-seizure medication,
may be used at any step for anxiety and pain management,
so (A) should be implemented. Non-opioid analgesics, such
as ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and
3 include opioid narcotics (D), and to maintain freedom from
pain, drugs should be given around the clock rather than by
the client s PRN requests.
5. The nurse is preparing to irrigate a client's indwelling
urinary catheter using an open technique. What action should
the nurse take after applying gloves?
• Empty the client's urinary drainage bag.
• Draw up the irrigating solution into the syringe.
• Secure the client's catheter to the drainage tubing.
• Use aseptic technique to instill the irrigating solution. -
...ANSWER...ANS - Draw up the irrigating solution into the
syringe.
RATIONALE: To irrigate an indwelling urinary catheter, the
nurse should first apply gloves, then draw up the irrigating
, solution into the syringe (B). The syringe is then attached to
the catheter and the fluid instilled, using aseptic technique
(D). Once the irrigating solution is instilled, the client's
catheter should be secured to the drainage tubing (C). The
urinary drainage bag can be emptied (A) whenever intake and
output measurement is indicated, and the instilled irrigating
fluid can be subtracted from the output at that time.
6. Which client care requires the nurse to wear barrier
gloves as required by the protocol for Standard Precautions?
• Removing the empty food tray from a client with a
urinary catheter.
• Washing and combing the hair of a client with a
fractured leg in traction.
• Administering oral medications to a cooperative client with
a wound infection.
• Emptying the urinary catheter drainage bag for a client with
Alzheimer's disease. Correct - ...ANSWER...ANS - Emptying
the urinary catheter drainage bag for a client with Alzheimer's
disease.
Rationale -
possible contact with body secretions, excretions, or broken
skin is an indication for wearing barrier (nonsterile) gloves.
Emptying a urine drainage bag requires the use of gloves (D).
(A, B, and C) do not require gloves.
7. What action should the nurse implement to prevent
the formation of a sacral ulcer for a client who is
immobile?
• Maintain in a lateral position using protective wrist and
vest devices.
• Position prone with a small pillow below the diaphragm.
• Raise the head and knee gatch when lying in a supine
position.
