HESI 799 RN EXIT EXAM FINAL SCRIPT 2026
COMPLETE SOLUTION SET
◉ The nurse makes a supervisory home visit to observe an
unlicensed assistive personnel (UAP) who is providing personal care
for a client with Alzheimer's disease. The nurse observes that
whenever the client gets upset, the UAP changes the subject. What
action should the nurse take in response to this observation?
a. Tell the UAP to offer more choices during the personal care to
prevent anxiety
b. Meet with the UAP later to role model more assertive
communication techniques
c. Assume care of the client to ensure that effective communication
is maintained.
d. Affirm that the UAP is using an effective strategy to reduce the
client's anxiety. Answer: d. Affirm that the UAP is using an effective
strategy to reduce the client's anxiety.
Rationale: Reduction is an effective technique is managing the
anxiety of client with Alzheimer's disease, so the nurse should affirm
the UAP is using an effective strategy (A). Nurse assertive
communication and offering more choices (B) may increase... an
agitation (C) is not indicated since the UAP is using redirection, an
effective strategy.
,◉ An older female who ambulates with a quad-cane prefers to use a
wheel chair because she has a halting and unsteady gait at times.
Which interventions should the nurse implement? (Select all that
apply)
a. Move personal items within client's reach
b. Lower bed to the lower possible position
c. Raise all bed rails when the client is resting
d. Give directions to call for assistance
e. Assist client to the bathroom in 2 hours.
f. Encourage the use of the wheelchair Answer: a. Move personal
items within client's reach
b. Lower bed to the lower possible position
d. Give directions to call for assistance
e. Assist client to the bathroom in 2 hours.
Rationale: A client who needs assistive devices, such as quad-cane is
at risk for falls. Precautions that should implement include ensuring
that personal items are within reach the bed is in the lowest position
and directions are given to call assistance to minimize the risk for
falls. Frequently assisting the client to the bathroom help ensure this
client does not go the bathroom by herself, thereby decreasing the
possibility of falling.
,◉ In evaluating the effectiveness of a postoperative client's
intermittent pneumatic compression devices, which assessment is
most important for the nurse to complete?
a. Evaluate the client's ability to use an incentive spirometer
b. Monitor the amount of drainage from the client's incision
c. Observe both lower extremities for redness and swelling
d. Palpate all peripheral pulse points for volume and strength
Answer: c. Observe both lower extremities for redness and swelling
Rationale: Intermittent compression devices (ICDs) are used to
reduce venous stasis and prevent venous thrombosis in mobile and
postoperative clients and its effectiveness is best assessed by
observing the client's lower extremities for early signs of
thrombophlebitis.
◉ A school-age child who weighs 42 pounds receives a post-
tonsillectomy prescription for promethazine (Phenergan) 0.5 mg/kg
IM to prevent postoperative nausea. The medication is available in
25 mg/ml ampules. How many ml should the nurse administer?
(Enter numeric value only. If rounding is required, round to the
nearest tenth).
0.4 Answer: 0.4
, Rationale: Convert pounds to kg 42lbs = 19.09 kg
Next calculate to prescribed dose, 0.5 mg x 1909 kg = 9.545
Then use the desired dose/ dose on hand x volume on hand
(9.545/25x1ml =0.3818=0.4 ml)
Or use ratio proportion (9.545 mg: x ml = 25 mg: 1ml
25x = 9.545
X= 0.3818 = 0.4)
◉ A nurse stops at the site of a motorcycle accident and finds a
young adult male lying face down in the road in a puddle of water. It
is raining, no one is available to send for help, and the cell phone is
in the car about 50 feet away. What action should the nurse take
first?
a. Examine the victim's body surfaces for arterial bleeding
b. Stabilize the victim's neck and roll over to evaluate his status
c. Return to the car to call emergency response 911 for help
d. Open the airway and initiate resuscitative measures Answer: b.
Stabilize the victim's neck and roll over to evaluate his status
◉ During a well-baby, 6-month visit, a mother tells the nurse that
her infant has had fewer ear infections than her 10-year-old
COMPLETE SOLUTION SET
◉ The nurse makes a supervisory home visit to observe an
unlicensed assistive personnel (UAP) who is providing personal care
for a client with Alzheimer's disease. The nurse observes that
whenever the client gets upset, the UAP changes the subject. What
action should the nurse take in response to this observation?
a. Tell the UAP to offer more choices during the personal care to
prevent anxiety
b. Meet with the UAP later to role model more assertive
communication techniques
c. Assume care of the client to ensure that effective communication
is maintained.
d. Affirm that the UAP is using an effective strategy to reduce the
client's anxiety. Answer: d. Affirm that the UAP is using an effective
strategy to reduce the client's anxiety.
Rationale: Reduction is an effective technique is managing the
anxiety of client with Alzheimer's disease, so the nurse should affirm
the UAP is using an effective strategy (A). Nurse assertive
communication and offering more choices (B) may increase... an
agitation (C) is not indicated since the UAP is using redirection, an
effective strategy.
,◉ An older female who ambulates with a quad-cane prefers to use a
wheel chair because she has a halting and unsteady gait at times.
Which interventions should the nurse implement? (Select all that
apply)
a. Move personal items within client's reach
b. Lower bed to the lower possible position
c. Raise all bed rails when the client is resting
d. Give directions to call for assistance
e. Assist client to the bathroom in 2 hours.
f. Encourage the use of the wheelchair Answer: a. Move personal
items within client's reach
b. Lower bed to the lower possible position
d. Give directions to call for assistance
e. Assist client to the bathroom in 2 hours.
Rationale: A client who needs assistive devices, such as quad-cane is
at risk for falls. Precautions that should implement include ensuring
that personal items are within reach the bed is in the lowest position
and directions are given to call assistance to minimize the risk for
falls. Frequently assisting the client to the bathroom help ensure this
client does not go the bathroom by herself, thereby decreasing the
possibility of falling.
,◉ In evaluating the effectiveness of a postoperative client's
intermittent pneumatic compression devices, which assessment is
most important for the nurse to complete?
a. Evaluate the client's ability to use an incentive spirometer
b. Monitor the amount of drainage from the client's incision
c. Observe both lower extremities for redness and swelling
d. Palpate all peripheral pulse points for volume and strength
Answer: c. Observe both lower extremities for redness and swelling
Rationale: Intermittent compression devices (ICDs) are used to
reduce venous stasis and prevent venous thrombosis in mobile and
postoperative clients and its effectiveness is best assessed by
observing the client's lower extremities for early signs of
thrombophlebitis.
◉ A school-age child who weighs 42 pounds receives a post-
tonsillectomy prescription for promethazine (Phenergan) 0.5 mg/kg
IM to prevent postoperative nausea. The medication is available in
25 mg/ml ampules. How many ml should the nurse administer?
(Enter numeric value only. If rounding is required, round to the
nearest tenth).
0.4 Answer: 0.4
, Rationale: Convert pounds to kg 42lbs = 19.09 kg
Next calculate to prescribed dose, 0.5 mg x 1909 kg = 9.545
Then use the desired dose/ dose on hand x volume on hand
(9.545/25x1ml =0.3818=0.4 ml)
Or use ratio proportion (9.545 mg: x ml = 25 mg: 1ml
25x = 9.545
X= 0.3818 = 0.4)
◉ A nurse stops at the site of a motorcycle accident and finds a
young adult male lying face down in the road in a puddle of water. It
is raining, no one is available to send for help, and the cell phone is
in the car about 50 feet away. What action should the nurse take
first?
a. Examine the victim's body surfaces for arterial bleeding
b. Stabilize the victim's neck and roll over to evaluate his status
c. Return to the car to call emergency response 911 for help
d. Open the airway and initiate resuscitative measures Answer: b.
Stabilize the victim's neck and roll over to evaluate his status
◉ During a well-baby, 6-month visit, a mother tells the nurse that
her infant has had fewer ear infections than her 10-year-old
