HESI 799 RN EXIT EXAM COMPREHENSIVE
STUDY GUIDE 2026 FULL ANSWERS VERIFIED
◉ 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 Answer: 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 Answer: 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 Answer: 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. Answer: 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 Answer: 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 Answer: 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.
STUDY GUIDE 2026 FULL ANSWERS VERIFIED
◉ 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 Answer: 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 Answer: 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 Answer: 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. Answer: 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 Answer: 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 Answer: 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.
