HESI 101 LATEST EXAM 2024 ACTUAL EXAM / HESI EXIT COMPREHENSIVE
REVIEW 120 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) | ALREADY GRADED A+
105. 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?
a- Remind staff to follow protective environment precautions b-
Gently flush the catheter lumen with sterile saline solution c-
Cleanse the site and change the transparent dressing
d- Confirm the necessity for continued use of the CVC - ANSWER-d- Confirm the necessity for
continued use of the CVC
Rationale: Increase the length of use increase the risk for infection. The CVC care bundle includes the
review of the need for continued use of the CVC. Effective hand hygiene and standard precautions
should be maintained but protective environment precautions are not needed. B is not needed if
continuous IV fluid are infused, ad may introduce contaminants. Use of a transparent dressing allows the
site to be visualized for any signs of infection but changing the dressing daily increases the risk for
infection
104. A client who sustained a head injury following an automobile collision is admitted to the hospital.
The nurse includes 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?
a- Increased Glasgow coma scale score b- Nuchal rigidity and
papilledema c- Confusion and papilledema d- Periorbital
ecchymosis. - ANSWER-c- Confusion and papilledema
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.
106. 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)?
a- An increased thirst with frequent urination b- Blood glucose range during past two weeks
was 110 to 125 mg/dl or 6.1 to 7.0 mmol/L(SI) c- Two-hour postprandial glucose tolerance
test (GTT) is 160 mg/dL or 8.9 mmol/L (SI)
,d- Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI). - ANSWER-d- Repeated fasting
blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
Rationale: FBS grater that 126 mg/dL or 7.0 mmol/L (SI) glucose (normal FBS range 70-110 mg/dL or 3.9
to 6.1 mmol/L (SI)) on at least two occasions is most diagnostic for DM. Classic symptoms of polyphagia,
polydipsia, and polyuria may not be present in type.....??
107. A new mother tells the nurse that she is unsure if she will be able to transition into parenthood.
What action should the nurse take?
a- Provide reassurance to the client that these feeling are normal after delivery
b- Discuss delaying the client's discharge from the hospital for another 24 hrs c-
Determine if she can ask for support from family, friend, or the baby's father
d- Explain the differences between postpartum blues and postpartum depression - ANSWER-c-
Determine if she can ask for support from family, friend, or the baby's father
Rationale: Emotional support of significant family and friends can help a new mother cope with anxiety
about transitioning to parenthood. The nurse should ask the client who is available to support her.
108. 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?
a- Establish the second IV site b- Asses the IV for blood return c- Stop the
normal saline infusion d- Discontinue the 24-gauge IV - ANSWER-c-
Stop the normal saline infusion
Rationale: If the IV has infiltrated or become dislodges, the fluid is infusing into surrounding tissue and
not into the vein. Stopping the infusion C is the priority action. Establishing another IV site is necessary
for fluid resuscitation after the infiltrated infusion is discontinuing the IV (D) is necessary due to the pain,
and a large gauge needle is preferable.
109. 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?
a- valuate her response to narcotic analgesia
,b- Asses the skin under the traction moleskin
c- Place a pillow under the involved lower left leg
d- Ensure proper alignment of the leg in traction - ANSWER-d- Ensure proper alignment of the leg in
traction
Rationale: A fractured hip results in external rotation and shortening of the affected extremity. With the
application of Buck‟s skin traction proper alignment ensures the transaction
S pull is exerted to align the fracture hip with the distal leg, immobilize the fractured bone, and minimize
muscle spasms and surrounding tissue injury related to the fracture. A should be implement but
improper pull of traction can increase pain and soft tissue damage. B and C should be implemented but
the greatest risk is improper alignment of the traction.
101. A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client
to perform a series of movements that require use of the facial muscles. What symptoms suggest that
the client has most likely experience a Bell‟s palsy rather than a stroke?
a- Slow onset of facial drooping associated with headache
b- Inability to close the affected eye, raise brow, or smile c-
A flat nasolabial fold on the right resulting in facial
asymmetry.
d- Drooling is present on right side of the mouth, but not on the left. - ANSWER-b- Inability to close
the affected eye, raise brow, or smile
Rationale: Because the motor function controlling eye closure, brow movement and smiling are all
carried on the 7th cranial (facial) nerve, the combination of symptoms directly relating to an impairment
of all branches of the facial nerve indicate that Bell‟s palsy has occurred.
102. The nurse is teaching a client how to perform colostomy irrigations. When observing the client's
return demonstration, which action indicated that the client understood the teaching?
, a- Turns to left the side to instill the irrigating solution into the stoma b-
Keeps the irrigating container less than 18 inches above the stoma c-
Instills 1,200 ml of irrigating solution to stimulate bowel evacuation
d- Inserts irrigating catheter deeper into stoma when cramping occurs - ANSWER-b- Keeps the
irrigating container less than 18 inches above the stoma
Rationale: Keeping the irrigating container less than 18 inches above the stoma permits the solution to
flow slowly with little excessive peristalsis does not cause immediate release of stool.
103. The nurse should teach the client to observe which precaution while taking dronedarone?
a- Stay out of direct sunlight b- Avoid grapefruits and its juice c-
Reduce the use of herbal supplements d- Minimize sodium intake. -
ANSWER-b- Avoid grapefruits and its juice Rationale: Grapefruit
increase the effect of dronedarone thereby increasing the possibility
of serious side effects. A does not cause a serious effect. C may
potentiate lethal arrhythmias and should be avoided. D does not
directly affect those taking dronedarone.
110. 55- An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna
boot is removed during a follow- up appointment, the nurse observes that the ulcer site contains bright
red tissue. What action should the nurse take in response to this finding?
a- Immediately apply a pressure dressing
b- Document the ongoing wound healing
c- Irrigate the wound with sterile saline
d- Obtain a capillary INR, measurement - ANSWER-b- Document the ongoing wound healing
REVIEW 120 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) | ALREADY GRADED A+
105. 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?
a- Remind staff to follow protective environment precautions b-
Gently flush the catheter lumen with sterile saline solution c-
Cleanse the site and change the transparent dressing
d- Confirm the necessity for continued use of the CVC - ANSWER-d- Confirm the necessity for
continued use of the CVC
Rationale: Increase the length of use increase the risk for infection. The CVC care bundle includes the
review of the need for continued use of the CVC. Effective hand hygiene and standard precautions
should be maintained but protective environment precautions are not needed. B is not needed if
continuous IV fluid are infused, ad may introduce contaminants. Use of a transparent dressing allows the
site to be visualized for any signs of infection but changing the dressing daily increases the risk for
infection
104. A client who sustained a head injury following an automobile collision is admitted to the hospital.
The nurse includes 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?
a- Increased Glasgow coma scale score b- Nuchal rigidity and
papilledema c- Confusion and papilledema d- Periorbital
ecchymosis. - ANSWER-c- Confusion and papilledema
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.
106. 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)?
a- An increased thirst with frequent urination b- Blood glucose range during past two weeks
was 110 to 125 mg/dl or 6.1 to 7.0 mmol/L(SI) c- Two-hour postprandial glucose tolerance
test (GTT) is 160 mg/dL or 8.9 mmol/L (SI)
,d- Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI). - ANSWER-d- Repeated fasting
blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
Rationale: FBS grater that 126 mg/dL or 7.0 mmol/L (SI) glucose (normal FBS range 70-110 mg/dL or 3.9
to 6.1 mmol/L (SI)) on at least two occasions is most diagnostic for DM. Classic symptoms of polyphagia,
polydipsia, and polyuria may not be present in type.....??
107. A new mother tells the nurse that she is unsure if she will be able to transition into parenthood.
What action should the nurse take?
a- Provide reassurance to the client that these feeling are normal after delivery
b- Discuss delaying the client's discharge from the hospital for another 24 hrs c-
Determine if she can ask for support from family, friend, or the baby's father
d- Explain the differences between postpartum blues and postpartum depression - ANSWER-c-
Determine if she can ask for support from family, friend, or the baby's father
Rationale: Emotional support of significant family and friends can help a new mother cope with anxiety
about transitioning to parenthood. The nurse should ask the client who is available to support her.
108. 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?
a- Establish the second IV site b- Asses the IV for blood return c- Stop the
normal saline infusion d- Discontinue the 24-gauge IV - ANSWER-c-
Stop the normal saline infusion
Rationale: If the IV has infiltrated or become dislodges, the fluid is infusing into surrounding tissue and
not into the vein. Stopping the infusion C is the priority action. Establishing another IV site is necessary
for fluid resuscitation after the infiltrated infusion is discontinuing the IV (D) is necessary due to the pain,
and a large gauge needle is preferable.
109. 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?
a- valuate her response to narcotic analgesia
,b- Asses the skin under the traction moleskin
c- Place a pillow under the involved lower left leg
d- Ensure proper alignment of the leg in traction - ANSWER-d- Ensure proper alignment of the leg in
traction
Rationale: A fractured hip results in external rotation and shortening of the affected extremity. With the
application of Buck‟s skin traction proper alignment ensures the transaction
S pull is exerted to align the fracture hip with the distal leg, immobilize the fractured bone, and minimize
muscle spasms and surrounding tissue injury related to the fracture. A should be implement but
improper pull of traction can increase pain and soft tissue damage. B and C should be implemented but
the greatest risk is improper alignment of the traction.
101. A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client
to perform a series of movements that require use of the facial muscles. What symptoms suggest that
the client has most likely experience a Bell‟s palsy rather than a stroke?
a- Slow onset of facial drooping associated with headache
b- Inability to close the affected eye, raise brow, or smile c-
A flat nasolabial fold on the right resulting in facial
asymmetry.
d- Drooling is present on right side of the mouth, but not on the left. - ANSWER-b- Inability to close
the affected eye, raise brow, or smile
Rationale: Because the motor function controlling eye closure, brow movement and smiling are all
carried on the 7th cranial (facial) nerve, the combination of symptoms directly relating to an impairment
of all branches of the facial nerve indicate that Bell‟s palsy has occurred.
102. The nurse is teaching a client how to perform colostomy irrigations. When observing the client's
return demonstration, which action indicated that the client understood the teaching?
, a- Turns to left the side to instill the irrigating solution into the stoma b-
Keeps the irrigating container less than 18 inches above the stoma c-
Instills 1,200 ml of irrigating solution to stimulate bowel evacuation
d- Inserts irrigating catheter deeper into stoma when cramping occurs - ANSWER-b- Keeps the
irrigating container less than 18 inches above the stoma
Rationale: Keeping the irrigating container less than 18 inches above the stoma permits the solution to
flow slowly with little excessive peristalsis does not cause immediate release of stool.
103. The nurse should teach the client to observe which precaution while taking dronedarone?
a- Stay out of direct sunlight b- Avoid grapefruits and its juice c-
Reduce the use of herbal supplements d- Minimize sodium intake. -
ANSWER-b- Avoid grapefruits and its juice Rationale: Grapefruit
increase the effect of dronedarone thereby increasing the possibility
of serious side effects. A does not cause a serious effect. C may
potentiate lethal arrhythmias and should be avoided. D does not
directly affect those taking dronedarone.
110. 55- An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna
boot is removed during a follow- up appointment, the nurse observes that the ulcer site contains bright
red tissue. What action should the nurse take in response to this finding?
a- Immediately apply a pressure dressing
b- Document the ongoing wound healing
c- Irrigate the wound with sterile saline
d- Obtain a capillary INR, measurement - ANSWER-b- Document the ongoing wound healing
