HESI Exit Exam 7 Graded A+ 2025

1. A client returns to the postoperative unit following an open reduction and internal fixation of a hip fix. the PN applies the prescribed sequential compression device (SCD) to both lower extremities. WHAT ACTION IS IMPORTANT WHEN TURNING THE CLIENT TO A LATERAL POSITION? Observe the SCDs continue to inflate and deflate when the client is turned. 2. While the PN assists a postoperative client with an incentive spirometer, the client experiences wound evisceration. WHAT ACTION SHOULD THE PN TAKE? Call for immediate assistance. 3. The PN finds a postoperative client lying in bed with a unsecured surgical dressing. After reinforcing the dressing, WHAT FOLLOW UP ASSESSMENT IS MOST IMPORTANT FOR THE PN TO IMPLEMENT? Vital signs measurement. 4. The scope of practice for the PN includes which CLIENT ASSESSMENT? An agitated client with b/l wrist restraints. 5. Which intervention is within the scope of practice for a PN? Demonstrating deep breathing and coughing to a postoperative client. 6. Which nursing activity is within the scope of practice for a PN? Observe client rotate the SQ site for an insulin pump. 7. The nurse is assessing care for residents on 12-bed unit in an extended care facility. The staff consists of 1 unlicensed UAP and 1 certified medication aide. WHICH TASK SHOULD THE NURSE PERFORM? Change a hydrocolloid dressing for a client with a stage II pressure ulcer. 8. A PN who works on a 16-bed of an extended care facility with an additional P and a UAP is told that the other PN will not be in because of illness. The facility manager agrees to obtain another UAP for the day. WHICH ACTION SHOULD THE PN TAKE? Prioritize assessment of safety issues in addition to administration of daily medication. 9. In working with UAP to provide care for an immobile client, WHICH TASK SHOULD THE NURSE PERFORM, RATHER THAN THE UAP? Cover a skin tear with a transparent dressing. 10. A nurse sees a college taking drugs from the hospital unit. WHAT ACTION SHOULD THE NURSE TAKE? Report the incident to the person in charge of the unit or nursing supervisor. 11. The PN finds a client who is assigned to another nurse bleeding from an IV site and the IV tubing and fluid are on the floor. The PN immediately applies a dressing to stop the bleeding. WHAT ACTION SHOULD THE PN TAKE NEXT? Enter computer documentation of the findings and the application of a dressing. 12. During report, the PN is told that a client has 4+ pitting edema of both feet and ankles. The PN observes the client's lower extremities and finds 2+ pitting edema b/l. WHAT ACTION SHOULD THE PN TAKE? Enter computer documentation of the finding. 13. The UAP working in a small community hospital obtains 0800 V/S measurements of clients on the unit. In reviewing these vital signs, WHICH MEASUREMENT WARRANTS IMMEDIATE INTERVENTION BY THE NURSE? A one-month-old infant with a HR of 80 bpm. 14. The nurse is assigned to care for four children. WHICH CHILD SHOULD BE ASSESSED FIRST? 18-month-old who has cystic fibrosis and is wheezing. 15. On a short-staffed unit of a long-term are facility, it is most important that the nurse assign the UAP to complete this morning care for the resident with which problem first? Frequent episodes of fecal incontinence. 16. Which client should the nurse assess first? A client who is ambulating with partial weight-bearing after a total hip replacement. 17. After report, the nurse receives the laboratory values for 4 clients. Which client requires the nurse's immediate intervention? The client who is: Trembling and has a glucose level of a 50 mg/dL. 18. The PN who is working as the charge nurse at an extended care facility is making assignments for the UAP working a 12-hour shift. WHICH RESOURCE IS MOST IMPORTANT IN GUIDING THE PN's assignments of the UAPs? The state's Nurse Practice Act regarding delegation to unlicensed personnel. 19. In caring for a client following a BKA, WHICH TASK IS BEST FOR THE NURSE TO DELEGATE TO THE UAP who is assisting with the care of this client? Empty and measure the drainage in the suction drainage device. 20. Which client should the nurse assign to a UAP? A client who has a regular HR after a pacemaker replacement and now needs to ambulate. 21. Which task could the nurse safely delegate to the UAP? Oral feeding of a two-year-old child after application of a hip spica cast. 22. The nurse assigns a UAP to feed a client who is at risk for aspiration. To ensure that the task is safely delegated, WHAT ACTION SHOULD THE NURSE IMPLEMENT? Observe the UAP's ability to implement precautions during feeding. 23. The nurse is in charge of a nursing unit in a long-term care facility. WHICH TASK IS BEST FOR THE NURSE ASSIGN TO A UAP who is helping with the care of SEVERAL clients? Cleanse the perineal area of client with urinary incontinence. 24. After morning dressing changes are completed, a male client who has paraplegia contaminates his ischial decubiti dressing with a diarrheal stool. WHAT ACTIVITY IS BEST FOR THE NURSE TO ASSIGN TO THE UAP? Provide perianal care and collect clean linens for the dressing change. 25. A new protocol for fall prevention is being implemented on the medical unit. During safety rounds, the nurse identifies that a UAP has omitted a vital component of the protocol. AFTER IMPLEMENTING THE MISSING COMPONENT, WHAT ACTION SHOULD THE PN TAKE? Supervise the UAP after reviewing the protocol. 26. The nurse asks a UAP for feedback about an assigned client. Instead of responding, the UAP walks away from the nurse, ignoring the question. WHAT ACTION IS THE BEST FOR THE NURSE TO TAKE? Approach the UAP to discuss the behavior and obtain the information needed about the client. 27. The principles of client advocacy are best demonstrated when the nurse exhibits which behaviors on behalf of the client? A Nuri who translates completes for a Spanish-speaking client to the HCP during rounds. 28. A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. WHAT RESPONSE SHOULD THE NURSE TAKE? Ask for a description of what happened during the night. 29. A female client complains to the nurse about being admitted to a semi-private room and expresses her displeasure because she requested a private room prior to admission. WHAT RESPONSE IS BEST FOR THE NURSE TO PROVIDE TO THIS CLIENT? Your healthcare provider must provide a written request to get you a private room. 30. Which nurse's behavior is a breach of client confidentiality according to the Health Insurance Portable Accountability Act (HIPPA) regulations? A daily report sheet with the information of the team's clients is taken home. 31. The nurse overhears a conversation between unlicensed assistive personnel (UAP) and another staff member in the hospital cafeteria line concerning a client's reaction to being given a diagnosis of terminal cancer. WHAT IS THE BEST NURSING ACTION? Approach the individuals involved and ask them to stop. 32. A terminally ill client and his family are requesting hospice care after discharge from the hospital an ask the nurse to explain what kind of care they should expect. The nurse should indicate that hospice philosophy focuses on what aspect of health care? Enhance symptom management to improve end of life quality. 33. A 54-year-old client was informed two days ago that the dx is terminal cancer. WHICH INTERVENTION WOULD BE MOST HELPFUL FOR THE SPOUSE AT THIS TIME? Ask the spouse to participate in the client's care within his/her capabilities and desires. 34. Wrist restrains were applied to a client who was severely agitated and disoriented. In monitoring the client, who is now asleep, WHICH FINDING SHOULD BE REPORTED TO THE CHARGE NURSE? Radial pulse volume decreases from +3 to +1. 35. An older male client is wandering on the skilled nursing unit. When he returns to his room, the UAP applies wrist restraints and tells the client that he is being restrained because he cannot be trusted to stay in his room. What violation of the patient's Bill of Rights has occurred? False Imprisonment. 36. The PN is reviewing the preoperative checklist for a client who is admitted for an emergency exploratory laparotomy. WHICH ACTION(s) SHOULD THE PN IMPLEMENT? SATA. - Determine the status of other diagnostic results and reports. - Report the Hgb and HCT results to the surgeon. 37. A male preoperative client who has already signed the informed consent for a surgical procedure confides to the PN that he is really frightened and unsure about undergoing the surgery. WHAT IS THE PRIORITY ACTION BY THE PN? Notify the charge nurse of the client's concerns about surgery. 38. A male client admitted the morning of his scheduled surgery tells the nurse that he drank a glass of water during the night. WHAT INTERVENTION WILL THE NURSE IMPLEMENT FIRST? Determine the amount of water and exact time it was taken. 39. The nurse is caring for an older client who is NPO after surgery. The client complaints that his mouth ad mucous membranes are dry. WHICH INTERVENTION SHOULD THE NURSE IMPLEMENT TO INCREASE THE CLIENT'S COMFORT? Perform oral hygiene frequently. 40. During preoperative preparation, the nurse should offer the client which explanation about why deep breathing exercising with an incentive spirometer are necessary after surgery? "Deep breathing exercises using the spirometer will help prevent postoperative complications." 41. A client is using an incentive spirometer on the first postoperative day after an inguinal Herniorrhaphy. THE NURSE SHOULD RE-TEACH the proper use of the spirometer when the client demonstrates what action? Blowing forcefully into the mouthpiece. 42. During immediate postoperative period, which condition has the highest priority when planning Nursing care? Respiratory Obstruction. 43. In assisting a client perform pursed lip breathing, the nurse should ensure that the client performs which action? Inhale through the nose with the mouth closed and exhale through pursed lips. 44. What is the best way for the nurse to assess the management of a client's postoperative pain? Inquire about the client's pain level 30 minutes following narcotic medication. 45. After change-of-shift report, the nurse makes rounds on a postoperative unit. WHICH CLIENT FINDING NECESSITATES THE IMMEDIATE ATTENTION OF THE NURSE? A client who is having bright red drainage from the rectum following a colonoscopy with polyp removal. 46. A nurse is assisting a client from the bathroom back to bed following minor surgical procedure. The client, still not fully alert, reports feeling nauseated and begins to vomit. WHAT IS THE FIRST ACTION THE NURSE SHOULD TAKE? Place client in a side lying position. 47. An elderly client in the early postoperative period requires close monitoring d/t aging and multi system changes. The nurse monitors respirations and auscultate breath sounds frequently. WHAT OTHER INTERVENTION SHOULD THE NURSE IMPLEMENT R/T THE CLIENT'S DECREASED VITAL CAPACITY? Evaluate pulse oxygen saturation. 48. The nurse is planning to ambulate a client who has been on bed rest for 24 hours following a colon resection. To ambulate this client safely, WHICH INTERVENTION SHOULD THE NURSE IMPLEMENT FIRST? Assist the client to a bedside sitting position. 49. The nurse is providing wound care for a client with a stage III pressure ulcer on the left heel. To achieve the goal, "An increase in granulation tissue will help develop within two weeks," WHICH INTERVENTION SHOULD THE NURSE IMPLEMENT? Irrigate wound with sterile NS. 50. The nurse is changing a postoperative dressing for a client with a horizontal lower abdominal incision. What method should the nurse remove the tape from the dressing? Remove all four sides by moving to the center of the incision. 51. The nurse observes a client whose surgical wound dressing is saturated with serosanguinous drainage 6 hours postoperatively. The Jackson-Pratt drainage unit is empty, is not compressed, and the stopper is open to air. WHAT IS THE FIRST ACTION SHOULD THE NURSE IMPLEMENT? Recompress the Jackson-Pratt bulb and put the stopper in place to reestablish the drain's suction. 52. The nurse empties a large amount of serous drainage from a postoperative client 's Hemovac drain. In what order should the nurse implement these procedures? (Place the first action on top and the last action on the bottom.) - Compress the drain. - Close the drain plug. - Discard the drainage. - Document the amount. 53. The nurse is preparing to perform a sterile wet-to-dry dressing change. In what order should the nurse implement these actions? - Pour sterile saline over sterile gauze dressings. - Don sterile gloves. - Place the wet sterile dressing in the wound. - Cover the wound with a dry sterile dressing. 54. The nurse is changing the dressing on a draining wound and irrigating the wound with sterile saline solution. WHAT PROTECTIVE EQUIPMENT SHOULD THE NURSE USE? - CLEAN gloves to remove the SOILED dressing, - and STERILE gloves to apply the NEW dressing. 55. When cleansing a wound with a drain. which technique should the PN use? Start at the drain site to avoid bringing the skin bacteria toward the wound. 56. The nurse should perform oral suctioning for a client with what problem? Dysphagia. 57. The nurse enters a client's room to perform a sterile dressing change. The nurse observes that the client is "gurgling" on oral secretions and coughing. WHICH ACTION SHOULD THE NURSE FIRST TAKE? Perform oral suctioning. 58. When providing oral care to an unconscious client who is a mouth breather and does not swallow, WHICH ACTION IS MOST IMPORTANT FOR THE NURSE TO IMPLEMENT? Use an oral suction catheter in the buccal cavity. 59. During vital sign assessment of a client, the nurse counts the left radial pulse at 88, and the pulse oximeter clipped to a finger on the left hand records a pulse rate of 68 with an oxygen saturation of 95%. What is the best initial action by the nurse? Reposition the oximeter clip. 60. In assisting a client obtain a sputum specimen, the nurse observes the client cough and spit a large amount of frothy saliva into the specimen’s collection cup. WHAT ACTION SHOULD THE NURSE IMPLEMENT NEXT? Reinstruct the client in coughing techniques to obtain another specimen. 61. The PN prepares to insert an indwelling urinary catheter for female client. To what order should the following interventions to be implemented? - Drape the client for privacy. - Open the catheterization kit. - Put on a pair of sterile gloves. - Lubricate tip of the catheter 2 inches. - Clean perineum from front to back. 62. When inserting an indwelling urinary catheter in a. female client, the nurse observes urine flow into the tubing. WHAT ACTION IS TAKEN NEXT? Insert the catheter an additional inch. 63. The PN is preparing to insert an indwelling catheter for an 89-year-old female client who has sever contractors of BLE. The client cries in pain when positioned supine while the nurse attempts to abduct the hips to visualize the perineum. WHAT ACTION SHOULD THE NURSE TAKE? Position laterally for posterior access in visualizing the meatus for insertion. 64. The nurse is inserting an indwelling catheter for an older male client who has urinary retention. What action is most important for the nurse to implement? Clamp the catheter after 1,000 mL is drained from the bladder. 65. A #16 urinary catheter with a 5 mL balloon is being removed by the nurse. After withdrawing 5 mL of fluid from the balloon, the nurse begins to withdraw the catheter while the client is in Semi-Fowler's position. However, the nurse meets resistance and the client voices discomfort. What action should the nurse take next? Attempt to withdraw additional fluid from the balloon. 66. The nurse is assessing an older resident of a LTC facility who has a hx of BPH and identifies that the client's bladder is distended. The HCP prescribes post-voided residual catheterization over the next 24h and placement of an indwelling catheter if the residual volume exceeds 100 mL.