HESI 799 RN Exit Exam 2025 Latest
complete Exam set Questions and
simplified correct Answers
A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle.
During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a
methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse
take? (Select all that apply.)
a. Collect multiple site screening culture for MRSA
b. Call healthcare provider for a prescription for linezolid (Zyrovix)
c. Place the client on contact transmission precautions
d. Obtain sputum specimen for culture and sensitivity
e. Continue to monitor for client sign of infection. - correct answer-a. Collect multiple site screening
culture for MRSA
c. Place the client on contact transmission precautions
e. Continue to monitor for client sign of infection.
Rationale: Until multi-site screening cultures come back negative (A), the client should be maintained on
contact isolation(C) to minimize the risk for nosocomial infection. Linezolid (Zyvox), a broad spectrum
anti-infecting, is not indicated, unless the client has an active skin structure infection cause by MRSA or
multidrug- resistant strains (MDRSP) of Staphylococcus aureus. A sputum culture is not indicated D)
based on the client's history is a wound infection.
A vacuum-assistive closure (VAC) device is being use to provide wound care for a client who has stage III
pressure ulcer on a below-the- knee (BKA) residual limb. Which intervention should the nurse implement
to ensure maximum effectiveness of the device?
a. Empty the device every 8 hours and change the dressing daily ensure sterility
b. Extended the transparent film dressing only to edge of wound to prevent tension.
c. Ensure the transparent dressing has no tears that might create vacuum leaks
d. Use an adhesive remover when changing the dressing to promote comfort. - correct answer-Ensure
the transparent dressing has no tears that might create vacuum leak
Rationale: The nurse should ensure that the VAC transparent film is intact, without tears or loose edges
C) because a break in the seal resulting in drying the wound and decreasing the vacuum. The vacuum-
assisted closure (VAC) device uses an open sponge in the wound bed, sealed with a transparent film
dressing and tube extrudes to a suction device that exert negative pressure to remove excess wound
fluid, reduce the bacterial count and stimulate granulation. The VAC is changed every other day or third
day, not (A) depending on the stage of wound healing and emptied when full or weekly. The transparent
wound dressing should extend 3 to 5 cm beyond the wound edges, not (B) to ensure and airtight seal.
Adhesive removers leave a reduce that binder transparent film adherence (D)
The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis
of "Ineffective airway clearance related to thick pulmonary secretions." Which intervention is most
important for the nurse to include in the client's plan of care?
a. Increase fluid intake to 3,000 ml/daily
,b. Administer O2 at 5L/mint per nasal cannula
c. Maintain the client in a semi Fowler's position
d. Provide frequent rest period. - correct answer-Increase fluid intake to 3,000 ml/daily
Rationale: The plan of care should include an increase in fluid intake (A) to liquefy and thin secretions for
easier removal of thick pulmonary secretion which facilitates airway clearance. (B) should be
implemented for signs of hypoxia (C) implemented to facilitate lung expansion, and (D) implemented for
activity intolerance, but these interventions do not have the priority of (A)
The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction
should the nurse provide to the adult male client?
a. Clearance around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle
b. Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours.
c. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized
specimens.
d. Urinate immediately into a urinal, and the lab will collect specimen every 6 hours, for the next 24
hours. - correct answer-Urinate at specific time, discard the urine, and collect all subsequent urine
during the next 24 hours.
Rationale: Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24
hours is the correct procedure for collecting 24-hour urine specimen. Discarding even one voided
specimen invalidate the test.
The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer
disease. What is the primary purpose of this drug classification?
a. Neutralize hydrochloric (HCI) acid in the stomach
b. Decreases the amount of HCL secretion by the parietal cells in the stomach
c. Inhibit action of acetylcholine by blocking parasympathetic nerve endings.
d. Destroys microorganisms causing stomach inflammation. - correct answer-Decreases the amount of
HCL secretion by the parietal cells in the stomach
Rationale: B correctly describe the action of histamine 2 receptor antagonist in helping to prevent peptic
ulcer disease.
The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with
Type 2 diabetes mellitus. Which information provides the best indicator of the drug's effectiveness?
a. Body max index (BMI) between 20 and 24
b. Blood pressure reading less than 120/80 mm Hg
c. Hemoglobin A1C (HbA1C) reading less than 7%
d. Self-reported glucose levels of 120-150 mg/dl. - correct answer-Hemoglobin A1C (HbA1C) reading less
than 7%
Rationale: Acarbose (Precose) delays carbohydrate absorption in the GI tract and causes the blood
glucose to rise slowly after a meal. The best indicator of acarbose effectiveness is a serum hemoglobin
A1 no greater than 7%, an indication of glucose level over time. Acarbose has no effect on pain or blood
pressure. Self-reported glucose levels of 120-150 reflect the blood sugar at the time taken and are not
the best indicator of drug effectiveness.
, The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the
client about recent use of which type of medication?
a. Antibiotics
b. Anticoagulants
c. Antihypertensive
d. Anticholinergics - correct answer-Antibiotics
Rationale: Antibiotic use may be altering the normal flora in the GI tract, resulting in the onset of
diarrhea, and several classes of antibiotics result in the overgrowth of Clostridium difficile, resulting in
severe diarrhea.
A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which
interventions should the nurse include in the infant's plan of care?
a. Give O2 at 6 L/nasal canula for 3 repeated oximetry screens below 90%
b. Administer diuretics via secondary infusion in the morning only
c. Evaluate heart rate for effectiveness of cardio tonic medications
d. Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples
e. Ensure uninterrupted and frequent rest periods between procedures. - correct answer-a. Give O2 at 6
L/nasal canula for 3 repeated oximetry screens below 90%
c. Evaluate heart rate for effectiveness of cardio tonic medications
d. Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples
e. Ensure uninterrupted and frequent rest periods between procedures.
Rationale: Pulse oximetry screening supports prescribed level of O2. HR provides an evaluative criterion
for cardiac medications, which reduce heart rate, increase strength contractions (inotropic effects) and
consequently affect systemic circulation and tissue oxygenation. Breast milk or basic formula provide 20
calories/ounce, so frequent feedings with high energy formula. D minimize fatigue is necessary.
The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to
40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving
100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse
implement these actions? (Place the first action on top and last action on the bottom.)
1. Start chest compressions with assisted manual ventilations
2. Administer epinephrine 0.01 mg/kg intraosseous (IO)
3. Apply pads and prepare for transthoracic pacing
4. Review the possible underlying causes for bradycardia. - correct answer-1. Start chest compressions
with assisted manual ventilations
2. Administer epinephrine 0.01 mg/kg intraosseous (IO)
3. Apply pads and prepare for transthoracic pacing
4. Review the possible underlying causes for bradycardia
Rationale: The American Heart Association guidelines recommend that the basic life support (BLS)
algorithm should be initiated immediately in pediatric clients who are unresponsive or have a heart rate
below 60 beats/minutes*** and exhibit signs of poor perfusion. This child is manifesting poor perfusion
as evidenced by a low blood pressure and poor oxygenation, so chest compression and assisted manual
ventilation should be provided first, followed by administration of drug therapy for persistent
complete Exam set Questions and
simplified correct Answers
A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle.
During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a
methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse
take? (Select all that apply.)
a. Collect multiple site screening culture for MRSA
b. Call healthcare provider for a prescription for linezolid (Zyrovix)
c. Place the client on contact transmission precautions
d. Obtain sputum specimen for culture and sensitivity
e. Continue to monitor for client sign of infection. - correct answer-a. Collect multiple site screening
culture for MRSA
c. Place the client on contact transmission precautions
e. Continue to monitor for client sign of infection.
Rationale: Until multi-site screening cultures come back negative (A), the client should be maintained on
contact isolation(C) to minimize the risk for nosocomial infection. Linezolid (Zyvox), a broad spectrum
anti-infecting, is not indicated, unless the client has an active skin structure infection cause by MRSA or
multidrug- resistant strains (MDRSP) of Staphylococcus aureus. A sputum culture is not indicated D)
based on the client's history is a wound infection.
A vacuum-assistive closure (VAC) device is being use to provide wound care for a client who has stage III
pressure ulcer on a below-the- knee (BKA) residual limb. Which intervention should the nurse implement
to ensure maximum effectiveness of the device?
a. Empty the device every 8 hours and change the dressing daily ensure sterility
b. Extended the transparent film dressing only to edge of wound to prevent tension.
c. Ensure the transparent dressing has no tears that might create vacuum leaks
d. Use an adhesive remover when changing the dressing to promote comfort. - correct answer-Ensure
the transparent dressing has no tears that might create vacuum leak
Rationale: The nurse should ensure that the VAC transparent film is intact, without tears or loose edges
C) because a break in the seal resulting in drying the wound and decreasing the vacuum. The vacuum-
assisted closure (VAC) device uses an open sponge in the wound bed, sealed with a transparent film
dressing and tube extrudes to a suction device that exert negative pressure to remove excess wound
fluid, reduce the bacterial count and stimulate granulation. The VAC is changed every other day or third
day, not (A) depending on the stage of wound healing and emptied when full or weekly. The transparent
wound dressing should extend 3 to 5 cm beyond the wound edges, not (B) to ensure and airtight seal.
Adhesive removers leave a reduce that binder transparent film adherence (D)
The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis
of "Ineffective airway clearance related to thick pulmonary secretions." Which intervention is most
important for the nurse to include in the client's plan of care?
a. Increase fluid intake to 3,000 ml/daily
,b. Administer O2 at 5L/mint per nasal cannula
c. Maintain the client in a semi Fowler's position
d. Provide frequent rest period. - correct answer-Increase fluid intake to 3,000 ml/daily
Rationale: The plan of care should include an increase in fluid intake (A) to liquefy and thin secretions for
easier removal of thick pulmonary secretion which facilitates airway clearance. (B) should be
implemented for signs of hypoxia (C) implemented to facilitate lung expansion, and (D) implemented for
activity intolerance, but these interventions do not have the priority of (A)
The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction
should the nurse provide to the adult male client?
a. Clearance around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle
b. Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours.
c. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized
specimens.
d. Urinate immediately into a urinal, and the lab will collect specimen every 6 hours, for the next 24
hours. - correct answer-Urinate at specific time, discard the urine, and collect all subsequent urine
during the next 24 hours.
Rationale: Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24
hours is the correct procedure for collecting 24-hour urine specimen. Discarding even one voided
specimen invalidate the test.
The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer
disease. What is the primary purpose of this drug classification?
a. Neutralize hydrochloric (HCI) acid in the stomach
b. Decreases the amount of HCL secretion by the parietal cells in the stomach
c. Inhibit action of acetylcholine by blocking parasympathetic nerve endings.
d. Destroys microorganisms causing stomach inflammation. - correct answer-Decreases the amount of
HCL secretion by the parietal cells in the stomach
Rationale: B correctly describe the action of histamine 2 receptor antagonist in helping to prevent peptic
ulcer disease.
The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with
Type 2 diabetes mellitus. Which information provides the best indicator of the drug's effectiveness?
a. Body max index (BMI) between 20 and 24
b. Blood pressure reading less than 120/80 mm Hg
c. Hemoglobin A1C (HbA1C) reading less than 7%
d. Self-reported glucose levels of 120-150 mg/dl. - correct answer-Hemoglobin A1C (HbA1C) reading less
than 7%
Rationale: Acarbose (Precose) delays carbohydrate absorption in the GI tract and causes the blood
glucose to rise slowly after a meal. The best indicator of acarbose effectiveness is a serum hemoglobin
A1 no greater than 7%, an indication of glucose level over time. Acarbose has no effect on pain or blood
pressure. Self-reported glucose levels of 120-150 reflect the blood sugar at the time taken and are not
the best indicator of drug effectiveness.
, The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the
client about recent use of which type of medication?
a. Antibiotics
b. Anticoagulants
c. Antihypertensive
d. Anticholinergics - correct answer-Antibiotics
Rationale: Antibiotic use may be altering the normal flora in the GI tract, resulting in the onset of
diarrhea, and several classes of antibiotics result in the overgrowth of Clostridium difficile, resulting in
severe diarrhea.
A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which
interventions should the nurse include in the infant's plan of care?
a. Give O2 at 6 L/nasal canula for 3 repeated oximetry screens below 90%
b. Administer diuretics via secondary infusion in the morning only
c. Evaluate heart rate for effectiveness of cardio tonic medications
d. Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples
e. Ensure uninterrupted and frequent rest periods between procedures. - correct answer-a. Give O2 at 6
L/nasal canula for 3 repeated oximetry screens below 90%
c. Evaluate heart rate for effectiveness of cardio tonic medications
d. Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples
e. Ensure uninterrupted and frequent rest periods between procedures.
Rationale: Pulse oximetry screening supports prescribed level of O2. HR provides an evaluative criterion
for cardiac medications, which reduce heart rate, increase strength contractions (inotropic effects) and
consequently affect systemic circulation and tissue oxygenation. Breast milk or basic formula provide 20
calories/ounce, so frequent feedings with high energy formula. D minimize fatigue is necessary.
The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to
40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving
100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse
implement these actions? (Place the first action on top and last action on the bottom.)
1. Start chest compressions with assisted manual ventilations
2. Administer epinephrine 0.01 mg/kg intraosseous (IO)
3. Apply pads and prepare for transthoracic pacing
4. Review the possible underlying causes for bradycardia. - correct answer-1. Start chest compressions
with assisted manual ventilations
2. Administer epinephrine 0.01 mg/kg intraosseous (IO)
3. Apply pads and prepare for transthoracic pacing
4. Review the possible underlying causes for bradycardia
Rationale: The American Heart Association guidelines recommend that the basic life support (BLS)
algorithm should be initiated immediately in pediatric clients who are unresponsive or have a heart rate
below 60 beats/minutes*** and exhibit signs of poor perfusion. This child is manifesting poor perfusion
as evidenced by a low blood pressure and poor oxygenation, so chest compression and assisted manual
ventilation should be provided first, followed by administration of drug therapy for persistent
