, HESI EXIT V1
1. A nurse is caring for a client who is post-operative day 2 following abdominal surgery. The
client's vital signs are: temperature 38.6°C (101.5°F), heart rate 110 bpm, respiratory rate
22/min, blood pressure 98/62 mmHg. The surgical wound appears red, swollen, and has
purulent drainage. Which action should the nurse take FIRST?
A Administer the prescribed antipyretic medication.
B Notify the healthcare provider immediately.
C Obtain a wound culture specimen.
D Apply a sterile dressing over the wound.
Correct Answer: B
Rationale: The client is exhibiting signs of a surgical site infection with systemic manifestations
(fever, tachycardia, hypotension). The nurse's priority is to notify the healthcare provider
immediately because this represents a potentially serious complication requiring prompt
medical intervention. While obtaining a wound culture (C) is important, it should be done after
the provider orders it. Administering antipyretics (A) and applying a sterile dressing (D) are
supportive measures but do not address the underlying infection .
2. A charge nurse is making assignments for a medical-surgical unit. Which client should be
assigned to the most experienced registered nurse?
A A client with diabetes mellitus requiring insulin administration.
B A client with heart failure receiving IV furosemide.
C A client who is 2 hours post-return from cardiac catheterization with a femoral sheath in
place.
D A client with pneumonia requesting pain medication.
Correct Answer: C
Rationale: The client who is 2 hours post-cardiac catheterization with a femoral sheath in place
is at highest risk for complications including bleeding, hematoma, pseudoaneurysm, and
retroperitoneal bleeding. This client requires frequent assessment of the access site, distal
pulses, and vital signs, and needs an experienced nurse who can recognize early signs of
complications .
,3. A nurse is preparing a client for a procedure that requires informed consent. The client states,
"I don't understand what the doctor told me about the risks." Which action should the nurse
take?
A Have the client sign the consent form and explain the procedure later.
B Explain the procedure and risks to the client.
C Notify the healthcare provider that the client needs further explanation.
D Document that the client refused to sign the consent form.
Correct Answer: C
Rationale: It is the healthcare provider's responsibility to obtain informed consent and explain
the procedure, risks, benefits, and alternatives. The nurse can witness the signature but cannot
provide the initial explanation. If the client does not understand, the nurse must notify the
provider so they can provide additional clarification .
4. A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is
appropriate for the nurse to delegate?
A Administering oral medications.
B Assessing a client's wound.
C Measuring intake and output.
D Teaching a client about dietary restrictions.
Correct Answer: C
Rationale: Measuring intake and output is a routine task that falls within the scope of practice
for UAP. It does not require nursing judgment or assessment skills. Administering medications
(A) requires nursing knowledge and is not within UAP scope. Wound assessment (C) requires
clinical judgment and is a nursing responsibility. Client teaching (D) requires specialized
knowledge and is the nurse's responsibility .
5. A nurse is caring for a client on a medical-surgical unit who has been placed in restraints.
Which intervention is most important for the nurse to include in the plan of care?
A Assess the client's skin integrity and neurovascular status every 2 hours.
B Keep the restraints tightly secured to prevent the client from freeing themselves.
C Apply the restraints for a maximum of 8 hours before reassessing.
D Place the client in a supine position while in restraints.
, Correct Answer: A
Rationale: When a client is in restraints, the most important intervention is frequent
assessment of skin integrity and neurovascular status to prevent complications such as pressure
injuries, nerve damage, and circulatory impairment. Restraints should be applied loosely
enough to allow two fingers to fit between the restraint and the client's skin. Restraints require
reassessment at least every 2 hours and a new order every 24 hours .
6. A nurse is preparing to insert a nasogastric (NG) tube for gastric decompression. Which action
should the nurse take to verify correct placement of the tube?
A Aspirate gastric contents and check the pH.
B Auscultate for air insufflation over the epigastric area.
C Observe for bubbling when the tube is placed in water.
D Measure the length of the tube from the nostril to the ear.
Correct Answer: A
Rationale: Aspirating gastric contents and checking the pH is the most reliable method to
confirm NG tube placement. Gastric contents typically have a pH of 4 or less. Auscultation (B) is
no longer recommended as a sole method because it can be misleading. Observing for bubbling
(C) is not a reliable method. Measuring tube length (D) is used to estimate insertion depth but
does not confirm placement .
7. A nurse is providing discharge teaching to a client with a new diagnosis of heart failure.
Which statement by the client indicates a need for further teaching?
A "I will weigh myself every morning before breakfast."
B "I should limit my sodium intake to less than 2,000 mg per day."
C "I can stop taking my diuretic if I feel better."
D "I will call my healthcare provider if I gain more than 2 pounds in a day."
Correct Answer: C
Rationale: Clients with heart failure should not stop taking their diuretic medication without
consulting their healthcare provider, even if they feel better. Stopping diuretics can lead to fluid
overload and worsening heart failure. Weighing daily (A), limiting sodium (B), and reporting
weight gain (D) are all appropriate self-management strategies .
1. A nurse is caring for a client who is post-operative day 2 following abdominal surgery. The
client's vital signs are: temperature 38.6°C (101.5°F), heart rate 110 bpm, respiratory rate
22/min, blood pressure 98/62 mmHg. The surgical wound appears red, swollen, and has
purulent drainage. Which action should the nurse take FIRST?
A Administer the prescribed antipyretic medication.
B Notify the healthcare provider immediately.
C Obtain a wound culture specimen.
D Apply a sterile dressing over the wound.
Correct Answer: B
Rationale: The client is exhibiting signs of a surgical site infection with systemic manifestations
(fever, tachycardia, hypotension). The nurse's priority is to notify the healthcare provider
immediately because this represents a potentially serious complication requiring prompt
medical intervention. While obtaining a wound culture (C) is important, it should be done after
the provider orders it. Administering antipyretics (A) and applying a sterile dressing (D) are
supportive measures but do not address the underlying infection .
2. A charge nurse is making assignments for a medical-surgical unit. Which client should be
assigned to the most experienced registered nurse?
A A client with diabetes mellitus requiring insulin administration.
B A client with heart failure receiving IV furosemide.
C A client who is 2 hours post-return from cardiac catheterization with a femoral sheath in
place.
D A client with pneumonia requesting pain medication.
Correct Answer: C
Rationale: The client who is 2 hours post-cardiac catheterization with a femoral sheath in place
is at highest risk for complications including bleeding, hematoma, pseudoaneurysm, and
retroperitoneal bleeding. This client requires frequent assessment of the access site, distal
pulses, and vital signs, and needs an experienced nurse who can recognize early signs of
complications .
,3. A nurse is preparing a client for a procedure that requires informed consent. The client states,
"I don't understand what the doctor told me about the risks." Which action should the nurse
take?
A Have the client sign the consent form and explain the procedure later.
B Explain the procedure and risks to the client.
C Notify the healthcare provider that the client needs further explanation.
D Document that the client refused to sign the consent form.
Correct Answer: C
Rationale: It is the healthcare provider's responsibility to obtain informed consent and explain
the procedure, risks, benefits, and alternatives. The nurse can witness the signature but cannot
provide the initial explanation. If the client does not understand, the nurse must notify the
provider so they can provide additional clarification .
4. A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is
appropriate for the nurse to delegate?
A Administering oral medications.
B Assessing a client's wound.
C Measuring intake and output.
D Teaching a client about dietary restrictions.
Correct Answer: C
Rationale: Measuring intake and output is a routine task that falls within the scope of practice
for UAP. It does not require nursing judgment or assessment skills. Administering medications
(A) requires nursing knowledge and is not within UAP scope. Wound assessment (C) requires
clinical judgment and is a nursing responsibility. Client teaching (D) requires specialized
knowledge and is the nurse's responsibility .
5. A nurse is caring for a client on a medical-surgical unit who has been placed in restraints.
Which intervention is most important for the nurse to include in the plan of care?
A Assess the client's skin integrity and neurovascular status every 2 hours.
B Keep the restraints tightly secured to prevent the client from freeing themselves.
C Apply the restraints for a maximum of 8 hours before reassessing.
D Place the client in a supine position while in restraints.
, Correct Answer: A
Rationale: When a client is in restraints, the most important intervention is frequent
assessment of skin integrity and neurovascular status to prevent complications such as pressure
injuries, nerve damage, and circulatory impairment. Restraints should be applied loosely
enough to allow two fingers to fit between the restraint and the client's skin. Restraints require
reassessment at least every 2 hours and a new order every 24 hours .
6. A nurse is preparing to insert a nasogastric (NG) tube for gastric decompression. Which action
should the nurse take to verify correct placement of the tube?
A Aspirate gastric contents and check the pH.
B Auscultate for air insufflation over the epigastric area.
C Observe for bubbling when the tube is placed in water.
D Measure the length of the tube from the nostril to the ear.
Correct Answer: A
Rationale: Aspirating gastric contents and checking the pH is the most reliable method to
confirm NG tube placement. Gastric contents typically have a pH of 4 or less. Auscultation (B) is
no longer recommended as a sole method because it can be misleading. Observing for bubbling
(C) is not a reliable method. Measuring tube length (D) is used to estimate insertion depth but
does not confirm placement .
7. A nurse is providing discharge teaching to a client with a new diagnosis of heart failure.
Which statement by the client indicates a need for further teaching?
A "I will weigh myself every morning before breakfast."
B "I should limit my sodium intake to less than 2,000 mg per day."
C "I can stop taking my diuretic if I feel better."
D "I will call my healthcare provider if I gain more than 2 pounds in a day."
Correct Answer: C
Rationale: Clients with heart failure should not stop taking their diuretic medication without
consulting their healthcare provider, even if they feel better. Stopping diuretics can lead to fluid
overload and worsening heart failure. Weighing daily (A), limiting sodium (B), and reporting
weight gain (D) are all appropriate self-management strategies .
