2025/2026 HESI 799 RN Exit Exam
Questions And Correct Answers Already
Graded A With Rationales
The nurse is triaging clients in an urgent care clinic. The client with which symptoms should be
referred to the health care provider immediately?
a. headache, photophobia, and nuchal rigidity
b. high fever, skin rash, and a productive cough
c. nausea, vomiting, and poor skin turgor
d. malaise, fever, and stiff, swollen joints
headache, photophobia, and nuchal rigidity
Rationale: Headache, photophobia, and nuchal rigidity are classic signs of meningeal infection, so
this client should immediately be referred to the health care provider. AC D do not have priority of
B
A client with Alzheimer's disease falls in the bathroom. The nurse notifies the charge nurse and
completes a fall follow-up assessment. What assessment finding warrants immediate intervention
by the nurse?
a. Urinary incontinence
b. Left forearm hematoma
c. Disorientation to surroundings
d. Dislodge intravenous site
Left forearm hematoma
Rationale: The left forearm hematoma may be indicative an injury, such as broken bone, that
requires immediate intervention. A may be likely be due to the inability to use the toilet due to
the fall. Disorientation is a common symptom of Alzheimer's disease. IV Dislodged is not an urgent
concern.
An adult male is brought to the emergency department by ambulance following a motorcycle
accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage
from both ears. Which assessment finding warrants immediate intervention by the nurse?
,a. Rebound abdominal tenderness
b. nausea and projectile vomiting
c. rib pain with deep inspiration
d. diminished bilateral breath sounds
b. nausea and projectile vomiting
Rationale: Projective vomiting is indicative of increasing intracranial pressure, which can lead to
ischemic brain damage or death, so this finding warrants immediate intervention. Rebound
abdominal tenderness may indicate internal bleeding. Diminished breath sound may be related to
pain. Rib pain with inspiration may indicate rib fracture.
The nurse has received funding to design a health promotion project for AfricanAmerican women
who are at risk for developing breast cancer. Which resource is most important in designing this
program?
a. A listing of African-American women so live in the community
b. Participation of community leaders in planning the program
c. Morbidity data for breast cancer in women of all races
d. Technical assistance to produce a video on breast self-examination.
Participation of community leaders in planning the program
After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the
x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should
the nurse implement?
a. Initiate intravenous fluid as prescribed
b. Notify the HCP of the need to reposition the catheter
c. Remove the catheter and apply direct pressure for 5 minutes.
d. Secure the catheter using aseptic technique
Initiate intravenous fluid as prescribed
Rationale: Venous blood return to the heart and drains from the subclavian vein into the superior
vena cava. The X-ray findings indicate proper placement of the CVC, so prescribed intravenous
,fluid can be started. A and B are not indicated at this time. The catheter should be secure
immediate following insertion (C)
A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which
assessment finding warrants immediate intervention by the nurse?
a. The client has asymmetrical chest wall expansion
b. The clients complain of pain at the insertion site
c. The client chest's x-ray indicates decreased pleural effusion
d. The client's arterial blood gases are pH 7.35, PaO2 85, Pa CO2 35, HCO3 26
a. The client has asymmetrical chest wall expansion
Rationale: A potential complication of thoracentesis is a pneumothorax. The symptoms of a
pneumothorax are uneven, unequal movement of the chest wall. A is an expected finding after the
local anesthetic effects "wear off" B is a desired result of thoracentesis and C is within normal
limits.
The home care nurse provide self-care instruction for a client with chronic venous insufficiency
caused by deep vein thrombosis. Which instructions should the nurse include in the client's
discharge teaching plan? Select all that apply
a. Avoid prolonged standing or sitting
b. Use a recliner for long periods of sitting
c. Continue wearing elastic stockings
d. Maintain the bed flat while sleeping
e. Cross legs at knee but not at ankle
a. Avoid prolonged standing or sitting
b. Use a recliner for long periods of sitting
c. Continue wearing elastic stockings
The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate
intervention?
a. Lip smacking and frequent eye blinking
, b. Shuffling gait and stooped posture
c. Rocks back and forth in the chair
d. Muscle spasms of the back and neck
d. Muscle spasms of the back and neck
A male client was transferred yesterday from the emergency department to the telemetry unit
because he had ST depression and resolved chest pain. When his EKG monitor alarms for
ventricular tachycardia (VT), what action should the nurse take first?
a. Determine the client's responsiveness and respirations
b. Bring the crash cart to the room to defibrillate the client.
c. Immediately initiate chest compressions.
d. Notify the emergency response team
a. Determine the client's responsiveness and respirations
Rationale: Activities, such as brushing teeth, can mimic the waveform of VI, so first he client
should be assessed (A) to determine if the alarm is accurate. The crash cart can be brought to the
room by someone else and defibrillation (B) delivered as indicated by the client's rhythm. Based on
as assessment of the client, CPR© as summoning the emergency response team (D) may be
indicated.
A young couple who has been unsuccessful in conceiving a child for over a year is seen in the
family planning clinic. During an initial visit, which intervention is most important for the nurse
to implement?
a. Determine current sexual practices
b. Prepare a female client for an ultrasound
c. Request a sperm sample for ovulation
d. Evaluate hormone levels on both clients
a. Determine current sexual practices
Rationale: First a history should be obtained including practices that might be related to the
infertility, such as douching, daily ejaculation or the male partner's exposure to heat, such as
frequent sauna or work environment which can decrease sperm production (A B or C) may be
indicated after a complete assessment is obtained.
Questions And Correct Answers Already
Graded A With Rationales
The nurse is triaging clients in an urgent care clinic. The client with which symptoms should be
referred to the health care provider immediately?
a. headache, photophobia, and nuchal rigidity
b. high fever, skin rash, and a productive cough
c. nausea, vomiting, and poor skin turgor
d. malaise, fever, and stiff, swollen joints
headache, photophobia, and nuchal rigidity
Rationale: Headache, photophobia, and nuchal rigidity are classic signs of meningeal infection, so
this client should immediately be referred to the health care provider. AC D do not have priority of
B
A client with Alzheimer's disease falls in the bathroom. The nurse notifies the charge nurse and
completes a fall follow-up assessment. What assessment finding warrants immediate intervention
by the nurse?
a. Urinary incontinence
b. Left forearm hematoma
c. Disorientation to surroundings
d. Dislodge intravenous site
Left forearm hematoma
Rationale: The left forearm hematoma may be indicative an injury, such as broken bone, that
requires immediate intervention. A may be likely be due to the inability to use the toilet due to
the fall. Disorientation is a common symptom of Alzheimer's disease. IV Dislodged is not an urgent
concern.
An adult male is brought to the emergency department by ambulance following a motorcycle
accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage
from both ears. Which assessment finding warrants immediate intervention by the nurse?
,a. Rebound abdominal tenderness
b. nausea and projectile vomiting
c. rib pain with deep inspiration
d. diminished bilateral breath sounds
b. nausea and projectile vomiting
Rationale: Projective vomiting is indicative of increasing intracranial pressure, which can lead to
ischemic brain damage or death, so this finding warrants immediate intervention. Rebound
abdominal tenderness may indicate internal bleeding. Diminished breath sound may be related to
pain. Rib pain with inspiration may indicate rib fracture.
The nurse has received funding to design a health promotion project for AfricanAmerican women
who are at risk for developing breast cancer. Which resource is most important in designing this
program?
a. A listing of African-American women so live in the community
b. Participation of community leaders in planning the program
c. Morbidity data for breast cancer in women of all races
d. Technical assistance to produce a video on breast self-examination.
Participation of community leaders in planning the program
After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the
x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should
the nurse implement?
a. Initiate intravenous fluid as prescribed
b. Notify the HCP of the need to reposition the catheter
c. Remove the catheter and apply direct pressure for 5 minutes.
d. Secure the catheter using aseptic technique
Initiate intravenous fluid as prescribed
Rationale: Venous blood return to the heart and drains from the subclavian vein into the superior
vena cava. The X-ray findings indicate proper placement of the CVC, so prescribed intravenous
,fluid can be started. A and B are not indicated at this time. The catheter should be secure
immediate following insertion (C)
A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which
assessment finding warrants immediate intervention by the nurse?
a. The client has asymmetrical chest wall expansion
b. The clients complain of pain at the insertion site
c. The client chest's x-ray indicates decreased pleural effusion
d. The client's arterial blood gases are pH 7.35, PaO2 85, Pa CO2 35, HCO3 26
a. The client has asymmetrical chest wall expansion
Rationale: A potential complication of thoracentesis is a pneumothorax. The symptoms of a
pneumothorax are uneven, unequal movement of the chest wall. A is an expected finding after the
local anesthetic effects "wear off" B is a desired result of thoracentesis and C is within normal
limits.
The home care nurse provide self-care instruction for a client with chronic venous insufficiency
caused by deep vein thrombosis. Which instructions should the nurse include in the client's
discharge teaching plan? Select all that apply
a. Avoid prolonged standing or sitting
b. Use a recliner for long periods of sitting
c. Continue wearing elastic stockings
d. Maintain the bed flat while sleeping
e. Cross legs at knee but not at ankle
a. Avoid prolonged standing or sitting
b. Use a recliner for long periods of sitting
c. Continue wearing elastic stockings
The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate
intervention?
a. Lip smacking and frequent eye blinking
, b. Shuffling gait and stooped posture
c. Rocks back and forth in the chair
d. Muscle spasms of the back and neck
d. Muscle spasms of the back and neck
A male client was transferred yesterday from the emergency department to the telemetry unit
because he had ST depression and resolved chest pain. When his EKG monitor alarms for
ventricular tachycardia (VT), what action should the nurse take first?
a. Determine the client's responsiveness and respirations
b. Bring the crash cart to the room to defibrillate the client.
c. Immediately initiate chest compressions.
d. Notify the emergency response team
a. Determine the client's responsiveness and respirations
Rationale: Activities, such as brushing teeth, can mimic the waveform of VI, so first he client
should be assessed (A) to determine if the alarm is accurate. The crash cart can be brought to the
room by someone else and defibrillation (B) delivered as indicated by the client's rhythm. Based on
as assessment of the client, CPR© as summoning the emergency response team (D) may be
indicated.
A young couple who has been unsuccessful in conceiving a child for over a year is seen in the
family planning clinic. During an initial visit, which intervention is most important for the nurse
to implement?
a. Determine current sexual practices
b. Prepare a female client for an ultrasound
c. Request a sperm sample for ovulation
d. Evaluate hormone levels on both clients
a. Determine current sexual practices
Rationale: First a history should be obtained including practices that might be related to the
infertility, such as douching, daily ejaculation or the male partner's exposure to heat, such as
frequent sauna or work environment which can decrease sperm production (A B or C) may be
indicated after a complete assessment is obtained.
