HESI Exit Exam V1 - Premium Review
Category: Physiological Integrity - Basic Care and Comfort
1. Question: A male client with a duodenal ulcer is receiving discharge
instructions. He states to the nurse, "I'm glad I can drink lots of milk now to
soothe my ulcer." What is the most appropriate follow-up action by the
nurse?
o a) Reinforce the client's understanding of the soothing properties of
milk.
o b) Suggest the client also consume frequent small meals to prevent
discomfort.
o c) Review with the client the need to avoid foods and beverages
high in milk and cream.
o d) Advise the client to switch to decaffeinated coffee and tea to further
protect the ulcer.
o Rationale: (c) is correct because diets rich in milk and cream
stimulate gastric acid secretion, which can exacerbate duodenal ulcers.
(a) is incorrect as milk increases acid production. (b) is a helpful
suggestion but doesn't directly address the misconception about dairy.
(d) is also good advice but less directly related to the client's statement
about milk.
Category: Physiological Integrity - Pharmacological and Parenteral Therapies
2. Question: A male client with hypertension returns for a follow-up visit. His
blood pressure is 158/106 mmHg, and he admits to not taking his newly
prescribed antihypertensive medication because it "makes him feel bad."
What is the most critical point the nurse should emphasize when explaining
the importance of hypertension control to this client?
o a) The potential for developing acute kidney injury due to glomerular
damage.
o b) The increased risk of blindness secondary to the development of
cataracts.
o c) The significantly elevated risk of stroke resulting from cerebral
hemorrhage.
o d) The possibility of experiencing heart block due to myocardial
damage.
o Rationale: (c) is the most critical risk associated with uncontrolled
hypertension and should be emphasized to promote medication
, adherence. While the other options are potential complications, stroke
due to hemorrhage is a major and potentially fatal consequence.
Category: Safety and Infection Control
3. Question: The nurse observes an unlicensed assistive personnel (UAP)
placing soft pillows along the side rails of a newly admitted client with a
seizure disorder. What is the priority nursing intervention?
o a) Ensure the UAP has positioned the pillows effectively to protect the
client during a seizure.
o b) Instruct the UAP to use padded side rail covers or soft blankets
instead of pillows.
o c) Delegate another task to the UAP and assume responsibility for
padding the side rails.
o d) Ask the UAP to use some of the pillows to position the client in a
side-lying (lateral) position.
o Rationale: (b) is the priority because pillows pose a suffocation risk
during a seizure and should not be used for padding. Padded covers or
blankets are the appropriate safety measure. (a) is incorrect as pillows
are not the correct padding. (c) is an option but directly instructing the
UAP on the correct method is more effective for future situations. (d)
while a side-lying position is important during a seizure, the
immediate concern is the hazardous padding.
Category: Psychosocial Integrity
4. Question: An adolescent with major depressive disorder has been taking
duloxetine (Cymbalta) for 12 days. Which of the following assessment
findings requires immediate nursing follow-up?
o a) Complains of mild nausea and loss of appetite.
o b) States they often feel fatigued and drowsy during the day.
o c) Exhibits a noticeable increase in sweating.
o d) Describes life without purpose and expresses feelings of
hopelessness.
o Rationale: (d) indicates a potential increase in suicidal ideation, a
known risk with SSRIs and SNRIs like Cymbalta, especially in
adolescents and young adults. This requires immediate assessment
and intervention. (a), (b), and (c) are common side effects of
duloxetine but do not pose the same immediate risk.
, Continuing this pattern, here are a few more examples focusing on different
aspects:
Category: Physiological Integrity - Respiratory and Cardiovascular
7. Question: During the assessment of an adult client using a partial rebreather
mask, the nurse observes that the oxygen reservoir bag does not fully deflate
with each inspiration, and the client's respiratory rate is 14 breaths per
minute. What is the most appropriate nursing action?
o a) Encourage the client to take deeper breaths.
o b) Remove the mask briefly to allow the bag to fully inflate.
o c) Increase the liter flow of oxygen being delivered to the mask.
o d) Document the assessment findings in the client's record.
o Rationale: (d) is correct because the reservoir bag should remain
partially inflated during inspiration to ensure the client is rebreathing a
portion of exhaled air mixed with oxygen. A respiratory rate of 14 is
within the normal range. The findings indicate proper mask function.
(a) is unnecessary as the breathing pattern seems adequate. (b) would
interrupt oxygen therapy. (c) might be needed if the bag were
collapsing, but the current assessment doesn't indicate this.
Category: Safety and Infection Control
16.Question: Before the first surgical procedure of the day, a part-time scrub
nurse asks the circulating nurse if a 3-minute surgical hand scrub is
sufficient preparation. Based on established surgical standards, what should
the circulating nurse's best response be?
o a) "Since it's the first case, perhaps a more experienced nurse should
perform the scrub."
o b) "Verify that you are following the operating room's specific policy
for surgical hand scrubs."
o c) "Hand scrubs between cases can be 3 minutes, but the initial scrub
of the day requires longer."
o d) "Please continue your surgical hand scrub for a total duration
of 5 minutes."
o Rationale: (d) aligns with established guidelines (typically 3-5
minutes for the initial scrub depending on the antiseptic agent). (a) is
unnecessary and potentially insulting. (b) while important, doesn't
directly answer the question about adequacy. (c) is generally true
Category: Physiological Integrity - Basic Care and Comfort
1. Question: A male client with a duodenal ulcer is receiving discharge
instructions. He states to the nurse, "I'm glad I can drink lots of milk now to
soothe my ulcer." What is the most appropriate follow-up action by the
nurse?
o a) Reinforce the client's understanding of the soothing properties of
milk.
o b) Suggest the client also consume frequent small meals to prevent
discomfort.
o c) Review with the client the need to avoid foods and beverages
high in milk and cream.
o d) Advise the client to switch to decaffeinated coffee and tea to further
protect the ulcer.
o Rationale: (c) is correct because diets rich in milk and cream
stimulate gastric acid secretion, which can exacerbate duodenal ulcers.
(a) is incorrect as milk increases acid production. (b) is a helpful
suggestion but doesn't directly address the misconception about dairy.
(d) is also good advice but less directly related to the client's statement
about milk.
Category: Physiological Integrity - Pharmacological and Parenteral Therapies
2. Question: A male client with hypertension returns for a follow-up visit. His
blood pressure is 158/106 mmHg, and he admits to not taking his newly
prescribed antihypertensive medication because it "makes him feel bad."
What is the most critical point the nurse should emphasize when explaining
the importance of hypertension control to this client?
o a) The potential for developing acute kidney injury due to glomerular
damage.
o b) The increased risk of blindness secondary to the development of
cataracts.
o c) The significantly elevated risk of stroke resulting from cerebral
hemorrhage.
o d) The possibility of experiencing heart block due to myocardial
damage.
o Rationale: (c) is the most critical risk associated with uncontrolled
hypertension and should be emphasized to promote medication
, adherence. While the other options are potential complications, stroke
due to hemorrhage is a major and potentially fatal consequence.
Category: Safety and Infection Control
3. Question: The nurse observes an unlicensed assistive personnel (UAP)
placing soft pillows along the side rails of a newly admitted client with a
seizure disorder. What is the priority nursing intervention?
o a) Ensure the UAP has positioned the pillows effectively to protect the
client during a seizure.
o b) Instruct the UAP to use padded side rail covers or soft blankets
instead of pillows.
o c) Delegate another task to the UAP and assume responsibility for
padding the side rails.
o d) Ask the UAP to use some of the pillows to position the client in a
side-lying (lateral) position.
o Rationale: (b) is the priority because pillows pose a suffocation risk
during a seizure and should not be used for padding. Padded covers or
blankets are the appropriate safety measure. (a) is incorrect as pillows
are not the correct padding. (c) is an option but directly instructing the
UAP on the correct method is more effective for future situations. (d)
while a side-lying position is important during a seizure, the
immediate concern is the hazardous padding.
Category: Psychosocial Integrity
4. Question: An adolescent with major depressive disorder has been taking
duloxetine (Cymbalta) for 12 days. Which of the following assessment
findings requires immediate nursing follow-up?
o a) Complains of mild nausea and loss of appetite.
o b) States they often feel fatigued and drowsy during the day.
o c) Exhibits a noticeable increase in sweating.
o d) Describes life without purpose and expresses feelings of
hopelessness.
o Rationale: (d) indicates a potential increase in suicidal ideation, a
known risk with SSRIs and SNRIs like Cymbalta, especially in
adolescents and young adults. This requires immediate assessment
and intervention. (a), (b), and (c) are common side effects of
duloxetine but do not pose the same immediate risk.
, Continuing this pattern, here are a few more examples focusing on different
aspects:
Category: Physiological Integrity - Respiratory and Cardiovascular
7. Question: During the assessment of an adult client using a partial rebreather
mask, the nurse observes that the oxygen reservoir bag does not fully deflate
with each inspiration, and the client's respiratory rate is 14 breaths per
minute. What is the most appropriate nursing action?
o a) Encourage the client to take deeper breaths.
o b) Remove the mask briefly to allow the bag to fully inflate.
o c) Increase the liter flow of oxygen being delivered to the mask.
o d) Document the assessment findings in the client's record.
o Rationale: (d) is correct because the reservoir bag should remain
partially inflated during inspiration to ensure the client is rebreathing a
portion of exhaled air mixed with oxygen. A respiratory rate of 14 is
within the normal range. The findings indicate proper mask function.
(a) is unnecessary as the breathing pattern seems adequate. (b) would
interrupt oxygen therapy. (c) might be needed if the bag were
collapsing, but the current assessment doesn't indicate this.
Category: Safety and Infection Control
16.Question: Before the first surgical procedure of the day, a part-time scrub
nurse asks the circulating nurse if a 3-minute surgical hand scrub is
sufficient preparation. Based on established surgical standards, what should
the circulating nurse's best response be?
o a) "Since it's the first case, perhaps a more experienced nurse should
perform the scrub."
o b) "Verify that you are following the operating room's specific policy
for surgical hand scrubs."
o c) "Hand scrubs between cases can be 3 minutes, but the initial scrub
of the day requires longer."
o d) "Please continue your surgical hand scrub for a total duration
of 5 minutes."
o Rationale: (d) aligns with established guidelines (typically 3-5
minutes for the initial scrub depending on the antiseptic agent). (a) is
unnecessary and potentially insulting. (b) while important, doesn't
directly answer the question about adequacy. (c) is generally true
