EXIT HESI -PN EXAM A PRACTICE QUESTION AND
ANSWERS LATEST VERSION 2024 VERIFIED
RATIONALE GRADED A+
With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and waist.
Slowing peristalsis also affects the emptying of the colon, resulting in constipation (C). (A) is not the
primary reason for the changes in body structure. (B) is not indicated because loss of muscle tone and
constipation are age-related changes. (D) dismisses the client's concerns and does not help her
understand the changes that she is experiencing.
Which situation demonstrates proper application of client confidentiality requirements for the Health
Insurance Portability and Accountability Act (HIPAA)?
Which question is most relevant to ask the parents when obtaining the history of a 2-year-old child
recently diagnosed with osteomyelitis?
Which physiologic finding in an older adult contributes to an adverse drug reaction?
Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients
with increased intracranial pressure (ICP)?
Which nursing intervention(s) should be implemented when caring for a client with bipolar disorder in
the manic phase? (Select all that apply.)
Which intervention(s) is(are) most helpful in evaluating the effectiveness of nursing and medical
treatments for dehydration in a 36-month-old child? (Select all that apply.)
Which instruction should the nurse provide to a client whose vision is being tested with a Snellen chart?
Which client is best to assign to a graduate PN who is being oriented to a renal unit?
Which assessment is most important for the nurse to implement when seeing a client with multiple
myeloma?
Which assessment finding indicates that nystatin (Mycostatin) swish and swallow, prescribed for a client
with oral candidiasis, has been effective?
Which assessment finding for a client with peritoneal dialysis requires immediate intervention by the
nurse?
When the nurse-manager posts a schedule for volunteers to be on call, one staff member immediately
signs up for all available 7-to-3 day shifts. Other staff members complain to the charge nurse that they
were not permitted the opportunity to be on call for the day shift. What action should the nurse-
manager implement?
When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they feel a
tingling sensation in their nipples (B) when let-down occurs. (A, C, and D) provide inaccurate information.
When the administration at a large urban medical center decides to establish a unit to care for clients
with infectious diseases, such as severe acute respiratory syndrome (SARS) and the avian flu, several
,EXIT HESI -PN EXAM A PRACTICE QUESTION AND
ANSWERS LATEST VERSION 2024 VERIFIED
RATIONALE GRADED A+
employees express fear related to caring for these clients. When choosing staff to work on this unit,
which action is best for the nurse-manager to take?
When faced with an impending disaster, hospital personnel may be alerted but should continue with
current client care assignments until further instructions are received (D). Evacuation is typically a
response of last resort that begins with clients who are most able to ambulate (A). (B) is premature and
is likely to increase the chaos if incoming casualties are anticipated. (C) is poor utilization of personnel.
When caring for a postpartum client, which intervention is best for the nurse to implement to promote
increased peripheral vascular activity?
When assisting a client who has undergone a right above-knee amputation with positioning in bed,
which action should the nurse include?
What instruction(s) related to foot care is(are) appropriate for the client with type 1 diabetes mellitus?
(Select all that apply.)
Use the following calculation (B):
Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who
usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative
unit. Which client would be best for the charge nurse to assign to this UAP?
Two days after swallowing 30 tablets of alprazolam (Xanax), a client with a history of depression is
hemodynamically stable but wants to leave the hospital against medical advice. Which nursing action(s)
is(are) most likely to maintain client safety?
Trochanter rolls (D) should be placed on the lateral aspects of the thighs to prevent external rotation of
the hips when the client is in a supine position. Although (A, B, and C) are supportive equipment used to
maintain proper positioning of the client who is immobile, it is most important to maintain the lower
extremities in the aligned anatomical position. A bed board (A) provides increased back support,
especially with a soft mattress. The footboard (B) maintains the feet in dorsiflexion and prevents foot
drop. The trapeze bar (C) allows the client to participate while turning in the bed, during transfers in and
out of bed, or performing upper arm exercises.
Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with chronic back pain.
Which action(s) should the nurse take when preparing the client for this type of pain relief? (Select all
that apply.)
Thrombus formation, closed clamp, or crystallized medication can cause resistance while flushing a
central line, so the line should be assessed for closed clamps (A) first. Irrigation with a larger syringe (B)
will not alleviate the cause for the resistance and can rupture the line. A central line infection (C) should
not cause resistance while flushing the line. The CVC should be flushed with normal saline (D) or a
diluted solution of heparin (10-100 U/mL) after (A) is completed, if necessary.
,EXIT HESI -PN EXAM A PRACTICE QUESTION AND
ANSWERS LATEST VERSION 2024 VERIFIED
RATIONALE GRADED A+
These are safe measures to implement during an amniocentesis to monitor for and prevent
complications (A, B, and D). During late pregnancy the bladder should be emptied so that it will not be
punctured, but during early pregnancy the bladder must be full to push the uterus upward (C). The
woman should be placed in a supine position with her hands across her chest (E).
These ABGs reveal respiratory alkalosis (B), and treatment depends on the underlying cause. Because
the client is only 6 hours postoperative, he or she should be assessed for pain because treating the pain
will correct the underlying problem. A Pao2 of 96 mm Hg does not indicate the need for an increase in
oxygen administration (A). The Paco2 indicates mild hyperventilation, so (C) is not indicated. In addition,
it is very difficult to change one's breathing pattern. The use of sodium bicarbonate (D) is indicated for
the treatment of metabolic acidosis, not respiratory alkalosis.
The UAP can be assigned to perform tasks that do not require the judgment of the nurse, such as
positioning the client and obtaining vital signs (C). (A and B) involve assessment, which should be
performed by a nurse. (D) involves initial client teaching, which should be performed by the nurse.
The role of the nurse-manager in the mediation process is to assess the problem, analyze the
information, and reframe it in a manner that might provide compromise (C). The staff do not have the
right to watch television (A) while being paid to work. (B) challenges the administrator and is likely to
alienate the administrator, causing anger and shutting off further communication. (D) is not a sound
rationale for the use of the television.
The RN is caring for a client who is in skeletal traction. Which activity should the RN assign to the PN?
The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure and drain fluid
collection from the middle ear. The tube's patency allows air and water to enter the middle ear, so the
client should be reeducated if the client swims (B) or allows water to enter the external ear. (A, C, and D)
reflect correct responses.
The PN can implement nursing care, such as (B). The PN assists the RN in the development of a teaching
plan and reinforces information to the client according to the plan. (A, C, and D) are outside the scope of
PN practice, but the PN can assist the RN in gathering data, implementing nursing care, and contributing
to the plan of care under the supervision of the RN.
The over-the-counter (OTC) vaginal cream interferes with obtaining a cervical cellular sample, alters
cytology analysis, and masks bacterial or sexually transmitted disease infections, so the Pap test should
be postponed (D). Although (A, B, and C) are indicated, the client needs further teaching for the return
visit to perform the Pap smear test.
The only RN on a surgical unit is performing an admission assessment on a client scheduled for surgery in
2 hours. The UAP reports to the RN that an unresponsive male client with a continuous feeding tube has
just vomited. Which action should the RN delegate to the UAP?
The older woman who wishes she could change the choices she has made in her lifetime is expressing
despair and is still searching for integrity (D). The nurse uses Erikson stages of development over the life
, EXIT HESI -PN EXAM A PRACTICE QUESTION AND
ANSWERS LATEST VERSION 2024 VERIFIED
RATIONALE GRADED A+
span to assess an older client's adjustment to aging and plans teaching strategies to assist the clients
attain integrity versus despair. (A, B, and C) are normal developmental tasks of older adults.
The nurse-manager should speak privately with the nurse (A) to assess the nurse's motives and to
discuss allowing other team members the opportunity to be on call for the day shift. (B) might become
confrontational. (C) is irrelevant. (D) is not warranted.
The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure
without specific instruction from the health care provider if which finding was documented?
The nurse should instruct the client to save the next urine sample (A) for observation of its appearance
and for possible urinalysis. The client is reporting symptoms that may indicate the onset of a urinary
tract infection. Increased fluid intake should be encouraged, unless contraindicated (B). (C) is only
necessary if a calculus (stone) is suspected. (D) is not indicated by this client's symptoms.
The nurse should encourage a laboring client to begin pushing at which point?
The nurse should count the client's respirations, and document both the respiratory rate set by the
ventilator and the client's independent respiratory rate (D). Never rely strictly on (A). Although the
client's spontaneous breaths will be shallow and machine-assisted breaths will be deep, it is important to
record machine-assisted breaths as well as the client's spontaneous breaths to get an overall respiratory
picture of the client (B and C).
The nurse recognizes which behavior(s) in a client as warning sign(s) of an impending suicide attempt?
(Select all that apply.)
The nurse plans to evaluate the effectiveness of a bronchodilator. Which assessment datum indicates
that the desired effect of a bronchodilator has been achieved?
The nurse performs tracheostomy suctioning on a comatose client. Place the interventions in order from
first to last.
The nurse performs an assessment on a client with heart failure. Which finding(s) is(are) consistent with
the diagnosis of left-sided heart failure? (Select all that apply.)
The nurse meets resistance while flushing a central venous catheter (CVC) at the subclavian site. Which
action should the nurse perform?
The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help
reduce the pain associated with the disease. Which instruction should the nurse provide to these
parents?
The nurse is teaching a client newly diagnosed with diabetes mellitus about the subcutaneous
administration of Regular and NPH insulin. Which statement indicates that the client needs further
instruction?
ANSWERS LATEST VERSION 2024 VERIFIED
RATIONALE GRADED A+
With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and waist.
Slowing peristalsis also affects the emptying of the colon, resulting in constipation (C). (A) is not the
primary reason for the changes in body structure. (B) is not indicated because loss of muscle tone and
constipation are age-related changes. (D) dismisses the client's concerns and does not help her
understand the changes that she is experiencing.
Which situation demonstrates proper application of client confidentiality requirements for the Health
Insurance Portability and Accountability Act (HIPAA)?
Which question is most relevant to ask the parents when obtaining the history of a 2-year-old child
recently diagnosed with osteomyelitis?
Which physiologic finding in an older adult contributes to an adverse drug reaction?
Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients
with increased intracranial pressure (ICP)?
Which nursing intervention(s) should be implemented when caring for a client with bipolar disorder in
the manic phase? (Select all that apply.)
Which intervention(s) is(are) most helpful in evaluating the effectiveness of nursing and medical
treatments for dehydration in a 36-month-old child? (Select all that apply.)
Which instruction should the nurse provide to a client whose vision is being tested with a Snellen chart?
Which client is best to assign to a graduate PN who is being oriented to a renal unit?
Which assessment is most important for the nurse to implement when seeing a client with multiple
myeloma?
Which assessment finding indicates that nystatin (Mycostatin) swish and swallow, prescribed for a client
with oral candidiasis, has been effective?
Which assessment finding for a client with peritoneal dialysis requires immediate intervention by the
nurse?
When the nurse-manager posts a schedule for volunteers to be on call, one staff member immediately
signs up for all available 7-to-3 day shifts. Other staff members complain to the charge nurse that they
were not permitted the opportunity to be on call for the day shift. What action should the nurse-
manager implement?
When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they feel a
tingling sensation in their nipples (B) when let-down occurs. (A, C, and D) provide inaccurate information.
When the administration at a large urban medical center decides to establish a unit to care for clients
with infectious diseases, such as severe acute respiratory syndrome (SARS) and the avian flu, several
,EXIT HESI -PN EXAM A PRACTICE QUESTION AND
ANSWERS LATEST VERSION 2024 VERIFIED
RATIONALE GRADED A+
employees express fear related to caring for these clients. When choosing staff to work on this unit,
which action is best for the nurse-manager to take?
When faced with an impending disaster, hospital personnel may be alerted but should continue with
current client care assignments until further instructions are received (D). Evacuation is typically a
response of last resort that begins with clients who are most able to ambulate (A). (B) is premature and
is likely to increase the chaos if incoming casualties are anticipated. (C) is poor utilization of personnel.
When caring for a postpartum client, which intervention is best for the nurse to implement to promote
increased peripheral vascular activity?
When assisting a client who has undergone a right above-knee amputation with positioning in bed,
which action should the nurse include?
What instruction(s) related to foot care is(are) appropriate for the client with type 1 diabetes mellitus?
(Select all that apply.)
Use the following calculation (B):
Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who
usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative
unit. Which client would be best for the charge nurse to assign to this UAP?
Two days after swallowing 30 tablets of alprazolam (Xanax), a client with a history of depression is
hemodynamically stable but wants to leave the hospital against medical advice. Which nursing action(s)
is(are) most likely to maintain client safety?
Trochanter rolls (D) should be placed on the lateral aspects of the thighs to prevent external rotation of
the hips when the client is in a supine position. Although (A, B, and C) are supportive equipment used to
maintain proper positioning of the client who is immobile, it is most important to maintain the lower
extremities in the aligned anatomical position. A bed board (A) provides increased back support,
especially with a soft mattress. The footboard (B) maintains the feet in dorsiflexion and prevents foot
drop. The trapeze bar (C) allows the client to participate while turning in the bed, during transfers in and
out of bed, or performing upper arm exercises.
Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with chronic back pain.
Which action(s) should the nurse take when preparing the client for this type of pain relief? (Select all
that apply.)
Thrombus formation, closed clamp, or crystallized medication can cause resistance while flushing a
central line, so the line should be assessed for closed clamps (A) first. Irrigation with a larger syringe (B)
will not alleviate the cause for the resistance and can rupture the line. A central line infection (C) should
not cause resistance while flushing the line. The CVC should be flushed with normal saline (D) or a
diluted solution of heparin (10-100 U/mL) after (A) is completed, if necessary.
,EXIT HESI -PN EXAM A PRACTICE QUESTION AND
ANSWERS LATEST VERSION 2024 VERIFIED
RATIONALE GRADED A+
These are safe measures to implement during an amniocentesis to monitor for and prevent
complications (A, B, and D). During late pregnancy the bladder should be emptied so that it will not be
punctured, but during early pregnancy the bladder must be full to push the uterus upward (C). The
woman should be placed in a supine position with her hands across her chest (E).
These ABGs reveal respiratory alkalosis (B), and treatment depends on the underlying cause. Because
the client is only 6 hours postoperative, he or she should be assessed for pain because treating the pain
will correct the underlying problem. A Pao2 of 96 mm Hg does not indicate the need for an increase in
oxygen administration (A). The Paco2 indicates mild hyperventilation, so (C) is not indicated. In addition,
it is very difficult to change one's breathing pattern. The use of sodium bicarbonate (D) is indicated for
the treatment of metabolic acidosis, not respiratory alkalosis.
The UAP can be assigned to perform tasks that do not require the judgment of the nurse, such as
positioning the client and obtaining vital signs (C). (A and B) involve assessment, which should be
performed by a nurse. (D) involves initial client teaching, which should be performed by the nurse.
The role of the nurse-manager in the mediation process is to assess the problem, analyze the
information, and reframe it in a manner that might provide compromise (C). The staff do not have the
right to watch television (A) while being paid to work. (B) challenges the administrator and is likely to
alienate the administrator, causing anger and shutting off further communication. (D) is not a sound
rationale for the use of the television.
The RN is caring for a client who is in skeletal traction. Which activity should the RN assign to the PN?
The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure and drain fluid
collection from the middle ear. The tube's patency allows air and water to enter the middle ear, so the
client should be reeducated if the client swims (B) or allows water to enter the external ear. (A, C, and D)
reflect correct responses.
The PN can implement nursing care, such as (B). The PN assists the RN in the development of a teaching
plan and reinforces information to the client according to the plan. (A, C, and D) are outside the scope of
PN practice, but the PN can assist the RN in gathering data, implementing nursing care, and contributing
to the plan of care under the supervision of the RN.
The over-the-counter (OTC) vaginal cream interferes with obtaining a cervical cellular sample, alters
cytology analysis, and masks bacterial or sexually transmitted disease infections, so the Pap test should
be postponed (D). Although (A, B, and C) are indicated, the client needs further teaching for the return
visit to perform the Pap smear test.
The only RN on a surgical unit is performing an admission assessment on a client scheduled for surgery in
2 hours. The UAP reports to the RN that an unresponsive male client with a continuous feeding tube has
just vomited. Which action should the RN delegate to the UAP?
The older woman who wishes she could change the choices she has made in her lifetime is expressing
despair and is still searching for integrity (D). The nurse uses Erikson stages of development over the life
, EXIT HESI -PN EXAM A PRACTICE QUESTION AND
ANSWERS LATEST VERSION 2024 VERIFIED
RATIONALE GRADED A+
span to assess an older client's adjustment to aging and plans teaching strategies to assist the clients
attain integrity versus despair. (A, B, and C) are normal developmental tasks of older adults.
The nurse-manager should speak privately with the nurse (A) to assess the nurse's motives and to
discuss allowing other team members the opportunity to be on call for the day shift. (B) might become
confrontational. (C) is irrelevant. (D) is not warranted.
The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure
without specific instruction from the health care provider if which finding was documented?
The nurse should instruct the client to save the next urine sample (A) for observation of its appearance
and for possible urinalysis. The client is reporting symptoms that may indicate the onset of a urinary
tract infection. Increased fluid intake should be encouraged, unless contraindicated (B). (C) is only
necessary if a calculus (stone) is suspected. (D) is not indicated by this client's symptoms.
The nurse should encourage a laboring client to begin pushing at which point?
The nurse should count the client's respirations, and document both the respiratory rate set by the
ventilator and the client's independent respiratory rate (D). Never rely strictly on (A). Although the
client's spontaneous breaths will be shallow and machine-assisted breaths will be deep, it is important to
record machine-assisted breaths as well as the client's spontaneous breaths to get an overall respiratory
picture of the client (B and C).
The nurse recognizes which behavior(s) in a client as warning sign(s) of an impending suicide attempt?
(Select all that apply.)
The nurse plans to evaluate the effectiveness of a bronchodilator. Which assessment datum indicates
that the desired effect of a bronchodilator has been achieved?
The nurse performs tracheostomy suctioning on a comatose client. Place the interventions in order from
first to last.
The nurse performs an assessment on a client with heart failure. Which finding(s) is(are) consistent with
the diagnosis of left-sided heart failure? (Select all that apply.)
The nurse meets resistance while flushing a central venous catheter (CVC) at the subclavian site. Which
action should the nurse perform?
The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help
reduce the pain associated with the disease. Which instruction should the nurse provide to these
parents?
The nurse is teaching a client newly diagnosed with diabetes mellitus about the subcutaneous
administration of Regular and NPH insulin. Which statement indicates that the client needs further
instruction?
