HESI 101 LATEST EXAM 2024 ACTUAL EXAM / HESI EXIT COMPREHENSIVE Rationale: Grapefruit increase the effect of dronedarone thereby increasing the possibility of serious
side effects. A does not cause a serious effect. C may potentiate lethal arrhythmias and should be
REVIEW 120 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES
avoided. D does not directly affect those taking dronedarone.
(VERIFIED ANSWERS) | ALREADY GRADED A+
101. A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the
client to perform a series of movements that require use of the facial muscles. What symptoms suggest 104. A client who sustained a head injury following an automobile collision is admitted to the hospital.
that the client has most likely experience a Bell‟s palsy rather than a stroke? The nurse includes the client's risk for developing increased intracranial pressure (ICP) in the plan of
care. Which signs indicate to the nurse that ICP has increased?
a- Slow onset of facial drooping associated with headache
a- Increased Glasgow coma scale score
b- Inability to close the affected eye, raise brow, or smile
b- Nuchal rigidity and papilledema
c- A flat nasolabial fold on the right resulting in facial
c- Confusion and papilledema
asymmetry.
d- Periorbital ecchymosis. - answer-c- Confusion and papilledema
d- Drooling is present on right side of the mouth, but not on the left. - answer-b- Inability to close the
affected eye, raise brow, or smile Rationale: papilledema is always an indicator of increased ICP, and confusion is usually the first sign of
increased ICP. Other options do not necessarily reflect increased ICP.
Rationale: Because the motor function controlling eye closure, brow movement and smiling are all
carried on the 7th cranial (facial) nerve, the combination of symptoms directly relating to an impairment
of all branches of the facial nerve indicate that Bell‟s palsy has occurred. 105. The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous
catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk
for infection?
102. The nurse is teaching a client how to perform colostomy irrigations. When observing the client's
return demonstration, which action indicated that the client understood the teaching? a- Remind staff to follow protective environment precautions
a- Turns to left the side to instill the irrigating solution into the stoma b- Gently flush the catheter lumen with sterile saline solution
b- Keeps the irrigating container less than 18 inches above the stoma c- Cleanse the site and change the transparent dressing
c- Instills 1,200 ml of irrigating solution to stimulate bowel evacuation d- Confirm the necessity for continued use of the CVC - answer-d- Confirm the necessity for continued
use of the CVC
d- Inserts irrigating catheter deeper into stoma when cramping occurs - answer-b- Keeps the irrigating
container less than 18 inches above the stoma Rationale: Increase the length of use increase the risk for infection. The CVC care bundle includes the
review of the need for continued use of the CVC. Effective hand hygiene and standard precautions
Rationale: Keeping the irrigating container less than 18 inches above the stoma permits the solution to should be maintained but protective environment precautions are not needed. B is not needed if
flow slowly with little excessive peristalsis does not cause immediate release of stool. continuous IV fluid are infused, ad may introduce contaminants. Use of a transparent dressing allows
the site to be visualized for any signs of infection but changing the dressing daily increases the risk for
infection
103. The nurse should teach the client to observe which precaution while taking dronedarone?
a- Stay out of direct sunlight
106. During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined
b- Avoid grapefruits and its juice to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks
later is most indicative that the client has diabetes mellitus (DM)?
c- Reduce the use of herbal supplements
a- An increased thirst with frequent urination
d- Minimize sodium intake. - answer-b- Avoid grapefruits and its juice
b- Blood glucose range during past two weeks was 110 to 125 mg/dl or 6.1 to 7.0 mmol/L(SI)
,c- Two-hour postprandial glucose tolerance test (GTT) is 160 mg/dL or 8.9 mmol/L (SI) a- valuate her response to narcotic analgesia
d- Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI). - answer-d- Repeated fasting
blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
b- Asses the skin under the traction moleskin
Rationale: FBS grater that 126 mg/dL or 7.0 mmol/L (SI) glucose (normal FBS range 70-110 mg/dL or 3.9
to 6.1 mmol/L (SI)) on at least two occasions is most diagnostic for DM. Classic symptoms of polyphagia,
polydipsia, and polyuria may not be present in type.....?? c- Place a pillow under the involved lower left leg
107. A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. d- Ensure proper alignment of the leg in traction - answer-d- Ensure proper alignment of the leg in
What action should the nurse take? traction
a- Provide reassurance to the client that these feeling are normal after delivery
b- Discuss delaying the client's discharge from the hospital for another 24 hrs Rationale: A fractured hip results in external rotation and shortening of the affected extremity. With the
application of Buck‟s skin traction proper alignment ensures the transaction
c- Determine if she can ask for support from family, friend, or the baby's father
S pull is exerted to align the fracture hip with the distal leg, immobilize the fractured bone, and minimize
d- Explain the differences between postpartum blues and postpartum depression - answer-c- Determine
muscle spasms and surrounding tissue injury related to the fracture. A should be implement but
if she can ask for support from family, friend, or the baby's father
improper pull of traction can increase pain and soft tissue damage. B and C should be implemented but
Rationale: Emotional support of significant family and friends can help a new mother cope with anxiety the greatest risk is improper alignment of the traction.
about transitioning to parenthood. The nurse should ask the client who is available to support her.
110. 55- An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna
108. A client who was admitted yesterday with severe dehydration is complaining of pain a 24-gauge IV boot is removed during a follow- up appointment, the nurse observes that the ulcer site contains bright
with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement red tissue. What action should the nurse take in response to this finding?
first?
a- Establish the second IV site
a- Immediately apply a pressure dressing
b- Asses the IV for blood return
c- Stop the normal saline infusion
b- Document the ongoing wound healing
d- Discontinue the 24-gauge IV - answer-c- Stop the normal saline infusion
Rationale: If the IV has infiltrated or become dislodges, the fluid is infusing into surrounding tissue and
c- Irrigate the wound with sterile saline
not into the vein. Stopping the infusion C is the priority action. Establishing another IV site is necessary
for fluid resuscitation after the infiltrated infusion is discontinuing the IV (D) is necessary due to the
pain, and a large gauge needle is preferable.
d- Obtain a capillary INR, measurement - answer-b- Document the ongoing wound healing
109. An elderly female is admitted because of a change in her level of sensorium. During the evening
shift, the client attempts to get out bed and falls, breaking her left hip. Buck's skin traction is applied to Rationale: Appearance of granulation tissue is the best indicator of increased venous returns and
the left leg while waiting for surgery. Which intervention is most important for the nurse to include in ongoing wound healing
this client's plan care?
, 111. At the end of a preoperative teaching session on pain management techniques, a client starts to cry 113. A client who had a right hip replacement 3 day ago is pale has diminished breath sound over the
and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client? left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is
scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical
pathway. Based on the client's symptoms, what recommendation should the nurse give the healthcare
a- Knowledge deficit provider?
b- Anxiety a- Reassess readiness for SNF transfer
c- Anticipatory grieving b- Obtain specimens for culture analysis
d- Pain (acute) - answer-b- Anxiety c- Confer with family about home care plans
Rationale: The client is demonstrating only anxiety. There is no indication that the client is presenting d- Arrange physical therapy for strengthening - answer-a- Reassess readiness for SNF transfer
signs of A, C or D
Rationale: Based on the client's symptoms, reassessing the client's readiness for rehabilitation in the SNF
112. The nurse notes a visible prolapse of the umbilical cord after a client experiences spontaneous is critical
rupture of the membranes during labor. What intervention should the nurse implement immediately?
114. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for
a- Administer oxygen by face mask at 6L/mint metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this
client's teaching plan? (Select all that apply.)
b- Transport the client for a cesarean delivery
a- Take an additional dose for signs of hyperglycemia
c- Elevate the presenting part off the cord
b- Recognize signs and symptoms of hypoglycemia
d- Place the client to a knee-chest position - answer-c- Elevate the presenting part off the cord
c- Report persist polyuria to the healthcare provider
Rationale: The nurse should immediately elevate the presenting part off the cord because when the
cord prolapses, the presenting part applies pressure to the cord, especially during each contraction, and d- Use sliding scale insulin for finger stick glucose elevation
reduces perfusion to the fetus. A can be delayed until pressure is removed from the cord. B and D are
important but do not have priority.
e- Take Glucophage with the morning and evening meal - answer-b- Recognize signs and symptoms of
hypoglycemia
side effects. A does not cause a serious effect. C may potentiate lethal arrhythmias and should be
REVIEW 120 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES
avoided. D does not directly affect those taking dronedarone.
(VERIFIED ANSWERS) | ALREADY GRADED A+
101. A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the
client to perform a series of movements that require use of the facial muscles. What symptoms suggest 104. A client who sustained a head injury following an automobile collision is admitted to the hospital.
that the client has most likely experience a Bell‟s palsy rather than a stroke? The nurse includes the client's risk for developing increased intracranial pressure (ICP) in the plan of
care. Which signs indicate to the nurse that ICP has increased?
a- Slow onset of facial drooping associated with headache
a- Increased Glasgow coma scale score
b- Inability to close the affected eye, raise brow, or smile
b- Nuchal rigidity and papilledema
c- A flat nasolabial fold on the right resulting in facial
c- Confusion and papilledema
asymmetry.
d- Periorbital ecchymosis. - answer-c- Confusion and papilledema
d- Drooling is present on right side of the mouth, but not on the left. - answer-b- Inability to close the
affected eye, raise brow, or smile Rationale: papilledema is always an indicator of increased ICP, and confusion is usually the first sign of
increased ICP. Other options do not necessarily reflect increased ICP.
Rationale: Because the motor function controlling eye closure, brow movement and smiling are all
carried on the 7th cranial (facial) nerve, the combination of symptoms directly relating to an impairment
of all branches of the facial nerve indicate that Bell‟s palsy has occurred. 105. The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous
catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk
for infection?
102. The nurse is teaching a client how to perform colostomy irrigations. When observing the client's
return demonstration, which action indicated that the client understood the teaching? a- Remind staff to follow protective environment precautions
a- Turns to left the side to instill the irrigating solution into the stoma b- Gently flush the catheter lumen with sterile saline solution
b- Keeps the irrigating container less than 18 inches above the stoma c- Cleanse the site and change the transparent dressing
c- Instills 1,200 ml of irrigating solution to stimulate bowel evacuation d- Confirm the necessity for continued use of the CVC - answer-d- Confirm the necessity for continued
use of the CVC
d- Inserts irrigating catheter deeper into stoma when cramping occurs - answer-b- Keeps the irrigating
container less than 18 inches above the stoma Rationale: Increase the length of use increase the risk for infection. The CVC care bundle includes the
review of the need for continued use of the CVC. Effective hand hygiene and standard precautions
Rationale: Keeping the irrigating container less than 18 inches above the stoma permits the solution to should be maintained but protective environment precautions are not needed. B is not needed if
flow slowly with little excessive peristalsis does not cause immediate release of stool. continuous IV fluid are infused, ad may introduce contaminants. Use of a transparent dressing allows
the site to be visualized for any signs of infection but changing the dressing daily increases the risk for
infection
103. The nurse should teach the client to observe which precaution while taking dronedarone?
a- Stay out of direct sunlight
106. During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined
b- Avoid grapefruits and its juice to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks
later is most indicative that the client has diabetes mellitus (DM)?
c- Reduce the use of herbal supplements
a- An increased thirst with frequent urination
d- Minimize sodium intake. - answer-b- Avoid grapefruits and its juice
b- Blood glucose range during past two weeks was 110 to 125 mg/dl or 6.1 to 7.0 mmol/L(SI)
,c- Two-hour postprandial glucose tolerance test (GTT) is 160 mg/dL or 8.9 mmol/L (SI) a- valuate her response to narcotic analgesia
d- Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI). - answer-d- Repeated fasting
blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
b- Asses the skin under the traction moleskin
Rationale: FBS grater that 126 mg/dL or 7.0 mmol/L (SI) glucose (normal FBS range 70-110 mg/dL or 3.9
to 6.1 mmol/L (SI)) on at least two occasions is most diagnostic for DM. Classic symptoms of polyphagia,
polydipsia, and polyuria may not be present in type.....?? c- Place a pillow under the involved lower left leg
107. A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. d- Ensure proper alignment of the leg in traction - answer-d- Ensure proper alignment of the leg in
What action should the nurse take? traction
a- Provide reassurance to the client that these feeling are normal after delivery
b- Discuss delaying the client's discharge from the hospital for another 24 hrs Rationale: A fractured hip results in external rotation and shortening of the affected extremity. With the
application of Buck‟s skin traction proper alignment ensures the transaction
c- Determine if she can ask for support from family, friend, or the baby's father
S pull is exerted to align the fracture hip with the distal leg, immobilize the fractured bone, and minimize
d- Explain the differences between postpartum blues and postpartum depression - answer-c- Determine
muscle spasms and surrounding tissue injury related to the fracture. A should be implement but
if she can ask for support from family, friend, or the baby's father
improper pull of traction can increase pain and soft tissue damage. B and C should be implemented but
Rationale: Emotional support of significant family and friends can help a new mother cope with anxiety the greatest risk is improper alignment of the traction.
about transitioning to parenthood. The nurse should ask the client who is available to support her.
110. 55- An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna
108. A client who was admitted yesterday with severe dehydration is complaining of pain a 24-gauge IV boot is removed during a follow- up appointment, the nurse observes that the ulcer site contains bright
with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement red tissue. What action should the nurse take in response to this finding?
first?
a- Establish the second IV site
a- Immediately apply a pressure dressing
b- Asses the IV for blood return
c- Stop the normal saline infusion
b- Document the ongoing wound healing
d- Discontinue the 24-gauge IV - answer-c- Stop the normal saline infusion
Rationale: If the IV has infiltrated or become dislodges, the fluid is infusing into surrounding tissue and
c- Irrigate the wound with sterile saline
not into the vein. Stopping the infusion C is the priority action. Establishing another IV site is necessary
for fluid resuscitation after the infiltrated infusion is discontinuing the IV (D) is necessary due to the
pain, and a large gauge needle is preferable.
d- Obtain a capillary INR, measurement - answer-b- Document the ongoing wound healing
109. An elderly female is admitted because of a change in her level of sensorium. During the evening
shift, the client attempts to get out bed and falls, breaking her left hip. Buck's skin traction is applied to Rationale: Appearance of granulation tissue is the best indicator of increased venous returns and
the left leg while waiting for surgery. Which intervention is most important for the nurse to include in ongoing wound healing
this client's plan care?
, 111. At the end of a preoperative teaching session on pain management techniques, a client starts to cry 113. A client who had a right hip replacement 3 day ago is pale has diminished breath sound over the
and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client? left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is
scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical
pathway. Based on the client's symptoms, what recommendation should the nurse give the healthcare
a- Knowledge deficit provider?
b- Anxiety a- Reassess readiness for SNF transfer
c- Anticipatory grieving b- Obtain specimens for culture analysis
d- Pain (acute) - answer-b- Anxiety c- Confer with family about home care plans
Rationale: The client is demonstrating only anxiety. There is no indication that the client is presenting d- Arrange physical therapy for strengthening - answer-a- Reassess readiness for SNF transfer
signs of A, C or D
Rationale: Based on the client's symptoms, reassessing the client's readiness for rehabilitation in the SNF
112. The nurse notes a visible prolapse of the umbilical cord after a client experiences spontaneous is critical
rupture of the membranes during labor. What intervention should the nurse implement immediately?
114. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for
a- Administer oxygen by face mask at 6L/mint metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this
client's teaching plan? (Select all that apply.)
b- Transport the client for a cesarean delivery
a- Take an additional dose for signs of hyperglycemia
c- Elevate the presenting part off the cord
b- Recognize signs and symptoms of hypoglycemia
d- Place the client to a knee-chest position - answer-c- Elevate the presenting part off the cord
c- Report persist polyuria to the healthcare provider
Rationale: The nurse should immediately elevate the presenting part off the cord because when the
cord prolapses, the presenting part applies pressure to the cord, especially during each contraction, and d- Use sliding scale insulin for finger stick glucose elevation
reduces perfusion to the fetus. A can be delayed until pressure is removed from the cord. B and D are
important but do not have priority.
e- Take Glucophage with the morning and evening meal - answer-b- Recognize signs and symptoms of
hypoglycemia
