HESI 799 RN Exit Exam ACTUAL EXAM 100 QUESTIONS AND
CORRECT ANSWERS WITH RATIONALES COVERING THE
MOST AND RECENT TESTED QUESTIONS GUARANTEE
OVER 80% PASSMARK
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.
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.
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
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.
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.
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.
A client who sustained a head injury following an automobile collision is admitted to the
hospital. The nurse include 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.
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.
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.
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.
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).
Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
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.
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.
, 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
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.
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. Evaluate 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.
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.
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
Document the ongoing wound healing
Rationale: Appearance of granulation tissue is the best indicator of increased venous retuns and
ongoing wound healing
At the end of a preoperative teaching session on pain management techniques, a client
starts to cry and states, "I just know I can't handle all the pain." What is the priority
CORRECT ANSWERS WITH RATIONALES COVERING THE
MOST AND RECENT TESTED QUESTIONS GUARANTEE
OVER 80% PASSMARK
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.
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.
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
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.
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.
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.
A client who sustained a head injury following an automobile collision is admitted to the
hospital. The nurse include 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.
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.
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.
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.
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).
Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
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.
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.
, 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
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.
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. Evaluate 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.
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.
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
Document the ongoing wound healing
Rationale: Appearance of granulation tissue is the best indicator of increased venous retuns and
ongoing wound healing
At the end of a preoperative teaching session on pain management techniques, a client
starts to cry and states, "I just know I can't handle all the pain." What is the priority
