HESI Comprehensive Exit Exam 1 – Verified
Questions, Answers & Rationales (2025
Updated) – Complete Exam Material
Description:
This document provides the full set of updated HESI
Comprehensive Exit Exam 1 questions for 2025, including correct
answers and detailed rationales. It covers a wide range of nursing
topics such as pharmacology, medical-surgical nursing, maternal-
child health, mental health, and community nursing. The material
is structured in a question-and-answer format with explanations,
making it ideal for exam preparation and review.
Questions and Answers with Rationales:
1. The nurse is preparing to administer a high volume saline
enema to a client. Which information is most important for the
nurse to obtain prior to administering the enema?
a. History of inflammatory bowel disorders.
b. Reason for administering the enema.
c. Feelings about having an enema.
d. Allergies to medications-Answer:- A
,(Enemas should be avoided or administered with extreme caution
to clients with inflammatory bowel disorders, so obtaining this
historical information has the highest priority. Reason for the
enema and feelings about it also provide valuable informa- tion,
but are not of the same priority as history of IBS. Allergies are not
necessary prior to enema administration.)
2. The nurse is teaching an adolescent girl with scoliosis about
a Milwaukee brace which her healthcare provider has prescribed.
Which instruction would be accurate?
a. Remove the brace one hour each day for bathing only.
b. Remove the brace twice daily for back range of motion
exercises.
c. Wear the brace against the bare skin.
d. Wear the brace in order to cure the spinal curvature-
Answer:- A
(The brace should be worn 23 hours a day and removed a total of
one hour a day for hygiene. Continuation of present activities will
promote a positive self concept. There really is no such thing as
back range of motion exercises. A T-shirt should be worn next to
the body and the brace put on over the T-shirt. The brace should
not be worn against bare skin. The brace will not cure the spinal
curvature, but only slow the progression of the scoliosis.)
,3. The clinic nurse identifies an elevation in the results of the
triple marker screening test for a client who is in the first
trimester of pregnancy. Which action should the nurse prepare
the client for?
a. Repeating the triple marker test.
b. Preparing for other diagnostic testing.
c. Counseling about possible fetal defects.
d. Securing permission for pregnancy termination-Answer:- B
(The triple marker screen measures maternal serum levels for
alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG),
and estriol, which screens for indi- cations of possible fetal
defects. An elevated result may be a false indicator, so other tests
are indicated. Repeating the triple marker screening is not
necessary or helpful. Elevated results warrant further testing with
ultrasound or amniocentesis before initiating counseling for birth
defects or discussing termination of pregnancy.)
4. The nurse is caring for critically ill clients. Which client
should be moni- tored for the development of neurogenic shock?
a. Heart failure.
b. Gastrointestinal hemorrhage.
c. Spinal cord injury.
d. Diabetes insipidus-Answer:- C
, (Spinal cord injuries place the client at high risk for the
development of neurogenic distributive shock. The development
to watch for in clients with heart failure is cardiogenic shock, in GI
bleeding is hemorrhagic shock, and in diabetes insipidus is
hypovolemic shock.)
5. Following major abdominal surgery, a male client's arterial
blood gas analysis reveals Pa0 2 95 mmHg and PaC0 2 50 mmHg.
He is receiving oxygen by nasal cannula at 4 liters/minute and is
reluctant to move in bed or deep breathe. Based on this
information, what action should the nurse implement at this
time?
a. Increase the oxygen flow to 6 liters/minute.
b. Encourage the use of an incentive spirometer.
c. Notify the healthcare provider of the crisis blood gas values.
d. Encourage the client to breathe slower-Answer:- B
(The blood gas reveals adequate oxygenation (Pa02 95) and
hypoventilation (PaC02
> 45). The client needs to be encouraged in activities that increase
the depth of breathing (e. g., use of the incentive spirometer).
Increasing oxygen rate will only increase an already adequate
Pa02. These are not crisis blood gas findings so no
Questions, Answers & Rationales (2025
Updated) – Complete Exam Material
Description:
This document provides the full set of updated HESI
Comprehensive Exit Exam 1 questions for 2025, including correct
answers and detailed rationales. It covers a wide range of nursing
topics such as pharmacology, medical-surgical nursing, maternal-
child health, mental health, and community nursing. The material
is structured in a question-and-answer format with explanations,
making it ideal for exam preparation and review.
Questions and Answers with Rationales:
1. The nurse is preparing to administer a high volume saline
enema to a client. Which information is most important for the
nurse to obtain prior to administering the enema?
a. History of inflammatory bowel disorders.
b. Reason for administering the enema.
c. Feelings about having an enema.
d. Allergies to medications-Answer:- A
,(Enemas should be avoided or administered with extreme caution
to clients with inflammatory bowel disorders, so obtaining this
historical information has the highest priority. Reason for the
enema and feelings about it also provide valuable informa- tion,
but are not of the same priority as history of IBS. Allergies are not
necessary prior to enema administration.)
2. The nurse is teaching an adolescent girl with scoliosis about
a Milwaukee brace which her healthcare provider has prescribed.
Which instruction would be accurate?
a. Remove the brace one hour each day for bathing only.
b. Remove the brace twice daily for back range of motion
exercises.
c. Wear the brace against the bare skin.
d. Wear the brace in order to cure the spinal curvature-
Answer:- A
(The brace should be worn 23 hours a day and removed a total of
one hour a day for hygiene. Continuation of present activities will
promote a positive self concept. There really is no such thing as
back range of motion exercises. A T-shirt should be worn next to
the body and the brace put on over the T-shirt. The brace should
not be worn against bare skin. The brace will not cure the spinal
curvature, but only slow the progression of the scoliosis.)
,3. The clinic nurse identifies an elevation in the results of the
triple marker screening test for a client who is in the first
trimester of pregnancy. Which action should the nurse prepare
the client for?
a. Repeating the triple marker test.
b. Preparing for other diagnostic testing.
c. Counseling about possible fetal defects.
d. Securing permission for pregnancy termination-Answer:- B
(The triple marker screen measures maternal serum levels for
alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG),
and estriol, which screens for indi- cations of possible fetal
defects. An elevated result may be a false indicator, so other tests
are indicated. Repeating the triple marker screening is not
necessary or helpful. Elevated results warrant further testing with
ultrasound or amniocentesis before initiating counseling for birth
defects or discussing termination of pregnancy.)
4. The nurse is caring for critically ill clients. Which client
should be moni- tored for the development of neurogenic shock?
a. Heart failure.
b. Gastrointestinal hemorrhage.
c. Spinal cord injury.
d. Diabetes insipidus-Answer:- C
, (Spinal cord injuries place the client at high risk for the
development of neurogenic distributive shock. The development
to watch for in clients with heart failure is cardiogenic shock, in GI
bleeding is hemorrhagic shock, and in diabetes insipidus is
hypovolemic shock.)
5. Following major abdominal surgery, a male client's arterial
blood gas analysis reveals Pa0 2 95 mmHg and PaC0 2 50 mmHg.
He is receiving oxygen by nasal cannula at 4 liters/minute and is
reluctant to move in bed or deep breathe. Based on this
information, what action should the nurse implement at this
time?
a. Increase the oxygen flow to 6 liters/minute.
b. Encourage the use of an incentive spirometer.
c. Notify the healthcare provider of the crisis blood gas values.
d. Encourage the client to breathe slower-Answer:- B
(The blood gas reveals adequate oxygenation (Pa02 95) and
hypoventilation (PaC02
> 45). The client needs to be encouraged in activities that increase
the depth of breathing (e. g., use of the incentive spirometer).
Increasing oxygen rate will only increase an already adequate
Pa02. These are not crisis blood gas findings so no
