HESI COMPREHENSIVE EXIT CERTIFICATION
EVALUATION 2026 FULL SOLUTION VIEW
AHEAD QUESTIONS
◉ An adult female who presents at the mental clinic trembling and
crying becomes distressed when the nurse attempts to conduct an
assessment. She complains about the number of questions that are
being asked, which she is convinced are going to cause her to have a
heart attack. What action should the nurse take?
A.Take the client's blood pressure and reassure her that questioning
will not cause a heart attack.
B.Explain that treatment is based on information obtained in the
assessment.
C.Encourage the client to relax so that she can provide the
information requested.
D.Empower the client to share her story of why she is here at the
mental health clinic.
Answer: D
Rationale:
The client is exhibiting signs of moderate anxiety, which include
voice tremors, shakiness, somatic complaints, and selective
inattention. (D) is the best method for addressing this client's level
of anxiety by creating a shared understanding of the client's
concerns. Although assessment of her blood pressure (A) might be a
,worthwhile intervention, reassuring her that questioning will not
cause a heart attack (A) is argumentative. (B) suggests that
treatment cannot be provided without the information, which is
manipulative. Asking the client to relax (C) is likely to increase her
anxiety.
◉ Which information is most concerning to the nurse when caring
for an older client with bilateral cataracts?
A.States having difficulty with color perception
B.Presents with opacity of the lens upon assessment
C.Complains of seeing a cobweb-type structure in the visual field
D.Reports the need to use a magnifying glass to see small print
Answer: C
Rationale:
Visualization of a cobweb- or hairnet-type structure is a sign of a
retinal detachment, which constitutes a medical emergency. Clients
with cataracts are at increased risk for retinal detachment (C).
Distorted color perception (A), opacity of the lens (B), and gradual
vision loss (D) are expected signs and symptom of cataracts, but do
not need immediate attention.
◉ Which intervention(s) should be performed by the nurse when
caring for a woman in the fourth stage of labor? (Select all that
apply.)
A.Maintain bed rest for the first 6 hours after delivery.
,B.Palpate and massage the fundus to maintain firmness.
C.Have client empty bladder if fundus is above umbilicus.
D.Check perineal pad for color and consistency of lochia.
E.Apply ice pack or witch hazel compresses to the perineum.
Answer: B,D,E
Rationale:
The fundus should be palpated and massaged frequently to prevent
hemorrhage (B). The lochia should be assessed to detect for
hemorrhage (D) and ice packs and witch hazel can decrease edema
and discomfort (E). Bed rest is only recommended for the first 2
hours (A). A full bladder is suspected if the fundus is deviated to the
right or left of the umbilicus (C).
◉ The nurse prepares to administer amoxicillin clavulanate
potassium (Augmentin) to a child weighing 15 kg. The prescription
is for 15 mg/kg every 12 hours by mouth. How many milliliters
should the nurse administer when supplied as below?
A.0.5
B.1.8
C.5
D.9
Answer: D
Rationale:15 mg/kg × 15 kg = 225 mg to be administered
Supply = 125 mg/5 mL
, (5 mL/125 mg) × 225 mg = 9 mL
or
(225 mg/125 mg) × 5 ml = 9 mL
◉ Which data obtained during a respiratory assessment for a 78-
year-old client is most important to report to the primary health
care provider?
A.Auscultation of vesicular breath sounds
B.Pulse oximetry reading of 89%
C.Arterial Pao2 of 86%
D.Resonance on percussion of the lungs
Answer: B
Rationale:
An oxygen saturation lower than 90% indicates hypoxia (B). (A, C,
and D) are all normal findings.
◉ When caring for a client with a tracheostomy, which intervention
should the nurse delegate to the unlicensed assistive personnel
(UAP)?
A.Teach the family about signs and symptoms of hypoxia.
B.Take the vital signs and obtain an O2 saturation level.
C.Evaluate the need for tracheal suctioning.
D.Revise the plan of care to include tracheostomy care.
EVALUATION 2026 FULL SOLUTION VIEW
AHEAD QUESTIONS
◉ An adult female who presents at the mental clinic trembling and
crying becomes distressed when the nurse attempts to conduct an
assessment. She complains about the number of questions that are
being asked, which she is convinced are going to cause her to have a
heart attack. What action should the nurse take?
A.Take the client's blood pressure and reassure her that questioning
will not cause a heart attack.
B.Explain that treatment is based on information obtained in the
assessment.
C.Encourage the client to relax so that she can provide the
information requested.
D.Empower the client to share her story of why she is here at the
mental health clinic.
Answer: D
Rationale:
The client is exhibiting signs of moderate anxiety, which include
voice tremors, shakiness, somatic complaints, and selective
inattention. (D) is the best method for addressing this client's level
of anxiety by creating a shared understanding of the client's
concerns. Although assessment of her blood pressure (A) might be a
,worthwhile intervention, reassuring her that questioning will not
cause a heart attack (A) is argumentative. (B) suggests that
treatment cannot be provided without the information, which is
manipulative. Asking the client to relax (C) is likely to increase her
anxiety.
◉ Which information is most concerning to the nurse when caring
for an older client with bilateral cataracts?
A.States having difficulty with color perception
B.Presents with opacity of the lens upon assessment
C.Complains of seeing a cobweb-type structure in the visual field
D.Reports the need to use a magnifying glass to see small print
Answer: C
Rationale:
Visualization of a cobweb- or hairnet-type structure is a sign of a
retinal detachment, which constitutes a medical emergency. Clients
with cataracts are at increased risk for retinal detachment (C).
Distorted color perception (A), opacity of the lens (B), and gradual
vision loss (D) are expected signs and symptom of cataracts, but do
not need immediate attention.
◉ Which intervention(s) should be performed by the nurse when
caring for a woman in the fourth stage of labor? (Select all that
apply.)
A.Maintain bed rest for the first 6 hours after delivery.
,B.Palpate and massage the fundus to maintain firmness.
C.Have client empty bladder if fundus is above umbilicus.
D.Check perineal pad for color and consistency of lochia.
E.Apply ice pack or witch hazel compresses to the perineum.
Answer: B,D,E
Rationale:
The fundus should be palpated and massaged frequently to prevent
hemorrhage (B). The lochia should be assessed to detect for
hemorrhage (D) and ice packs and witch hazel can decrease edema
and discomfort (E). Bed rest is only recommended for the first 2
hours (A). A full bladder is suspected if the fundus is deviated to the
right or left of the umbilicus (C).
◉ The nurse prepares to administer amoxicillin clavulanate
potassium (Augmentin) to a child weighing 15 kg. The prescription
is for 15 mg/kg every 12 hours by mouth. How many milliliters
should the nurse administer when supplied as below?
A.0.5
B.1.8
C.5
D.9
Answer: D
Rationale:15 mg/kg × 15 kg = 225 mg to be administered
Supply = 125 mg/5 mL
, (5 mL/125 mg) × 225 mg = 9 mL
or
(225 mg/125 mg) × 5 ml = 9 mL
◉ Which data obtained during a respiratory assessment for a 78-
year-old client is most important to report to the primary health
care provider?
A.Auscultation of vesicular breath sounds
B.Pulse oximetry reading of 89%
C.Arterial Pao2 of 86%
D.Resonance on percussion of the lungs
Answer: B
Rationale:
An oxygen saturation lower than 90% indicates hypoxia (B). (A, C,
and D) are all normal findings.
◉ When caring for a client with a tracheostomy, which intervention
should the nurse delegate to the unlicensed assistive personnel
(UAP)?
A.Teach the family about signs and symptoms of hypoxia.
B.Take the vital signs and obtain an O2 saturation level.
C.Evaluate the need for tracheal suctioning.
D.Revise the plan of care to include tracheostomy care.
