HESI RN COMPREHENSIVE EXIT EXAM VERSION I- 75+ QUESTIONS AND
ANSWERS WITH RATIONALES|WELL STRUCTURED|A+ GRADED|
QUESTIONS ANSWERS
D
The nurse is monitoring neurological vital signs for a male client
who lost consciousness after falling and hitting his head. Which (Neurological vital signs include serial assessments of TPR, blood
assessment finding is the earliest and most sensitive indication of
pressure, and components of the Glasgow coma scale (GCS),
altered cerebral function?
which includes verbal, musculoskeletal, and pupillary responses.
a. Unequal pupils.
A change in the client's level of consciousness, as indicated by
b. Loss of central reflexes.
responses to commands during the GCS, is the first and the most
c. Inability to open the eyes.
sensitive sign of change in cerebral function. The other assess-
d. Change in level of consciousness.
ment data choices are late signs of altered cerebral function.)
D
(A common genital tract infection in females is candidiasis, which
A nurse is planning to teach self-care measures to a female client is an overgrowth of the normal vaginal flora of Candida albi-
about prevention of yeast infections. Which instructions should the cans that thrives in an environment that is warm and moist and
nurse provide? is perpetuated by tight-fitting clothing, underwear, or pantyhose
a. Use a douche preparation no more than once a month. made of nonabsorbent materials. The client should wear clothing
b. Increase daily intake of fiber and leafy green vegetables. that is loose fitting and absorbent, such as cotton underwear,
c. Select nylon underwear that is loose-fitting, white, and comfort- and avoid using bubble-bath or bath salts which further irritate
able. sensitive genital tissue. Douching is not recommended because
d. Avoid tight-fitting clothing and do not use bubble-bath or bath it can irritate vaginal tissue, alter pH, and contribute to fungal
salts. growth. While increasing dietary fiber intake encourages healthy,
nutritional guidelines, it is not the focus of the teaching. Cotton, not
nylon undergarments, provide absorbancy and reduce moisture in
the perineal area.)
D
A client who has active tuberculosis (TB) is admitted to the med-
ical unit. What action is most important for the nurse to implement? (Active tuberculosis requires implementation of airborne precau-
tions, so the client should be assigned to a negative pressure
a. Place an isolation cart in the hallway. air-flow room. Although isolation gowns and isolation carts should
b. Fit the client with a respirator mask. be implemented for clients in isolation with contact precautions, it
c. Don a clean gown for client care. is most important that air flow from the room is minimized when the
d. Assign the client to a negative air-flow room. client has TB. The respirator mask should be implemented when
the client leaves the isolation environment.)
The nurse is planning to conduct nutritional assessments and diet
teaching to clients at a family health clinic. Which individual has A
the greatest nutritional and energy demands?
a. A pregnant woman. A pregnant woman's metabolic demands are 20 to 24% more than
b. A teenager beginning puberty. the basic metabolic rate. The other clients require only 15 to 20%
c. A 3-month-old infant. more than the basic metabolic rate.
d. A school-aged child.
B
(Primary nursing is a model of delivery of care where a nurse is
What nursing delivery of care provides the nurse to plan and direct
accountable for planning care for clients around the clock. Func-
care of a group of clients over a 24-hour period?
tional nursing is a care delivery model that provides client care by
a. Team nursing.
assignment of functions or tasks. Team nursing is a care delivery
b. Primary nursing.
model where assignments to a group of clients are provided by a
c. Case management.
mixed-staff team. Case management is the delivery of care that
d. Functional nursing.
uses a collaborative process of assessment, planning, facilitation,
and advocacy for options and services to meet an individual's
health needs and promote quality cost-effective outcomes.)
A
Which approach should the nurse use when preparing a toddler
(Imitation is one of the most distinguishing characteristics of tod-
for a procedure?
dler play, so demonstration of a procedure on a doll enables a
non-threatening, dramatic experience that can help prepare the
a. Demonstrate the procedure using a doll.
toddler for the actual procedure. The primary developmental task
b. Avoid asking the child to make choices.
in toddlerhood is acquiring a sense of autonomy, so giving choices
c. Plan a teaching session to last about 20 minutes.
whenever possible to a toddler is recommended, not avoiding
d. Show equipment but prevent child from handling it.
asking the toddler to make a choice. Since the toddler's attention
span is short, teaching sessions should be brief and can be
, HESI RN COMPREHENSIVE EXIT EXAM VERSION I- 75+ QUESTIONS AND
ANSWERS WITH RATIONALES|WELL STRUCTURED|A+ GRADED|
QUESTIONS ANSWERS
repeated for reinforcement. Showing the equipment before its use
helps relieve anxiety, but the child should be allowed to handle
some of the equipment to prevent frustration and alleviate fear.)
The nurse is caring for a client who is the daughter of a local
politician. When the nurse approaches a man who is reading the D
names on the hall doors, he identifies himself as a reporter for
the local newspaper and requests information about the client's (Confidentiality is the nurse's primary responsibility and is sup-
status. Which standard of nursing practice should the nurse use ported by HIPAA, which mandates that personal information is
to respond? not disclosed and access to sensitive client information is limited.
a. Caring. Caring involves the nurse's concern about how the client experi-
b. Veracity. ences the world. Veracity is the nurse's duty to tell the truth and not
c. Advocacy. deceive others. Advocacy is support of the client's best interests.)
d. Confidentiality.
A male client diagnosed with antisocial personality disorder is
morbidly obese and is placed on a low fat, low calorie diet. At D
dinner the nurse notes that he is trying to get other clients on the
unit to give him part of their meals. What intervention should the (The nurse should provide a reality check by helping the client
nurse implement? realize that there are consequences to his behavior. Removing
the client from the room or table does not help the client realize
a. Remove the client from the table and have him sit alone. that his behavior is manipulative and harmful to himself as well as
b. Send the client back to his room and do not allow him to eat. others. This behavior needs to be documented, but does not need
c. Report the behavior to the on-call psychologist immediately. to be reported immediately.)
d. Confront the client about the consequences of the behavior.
The nurse is assessing a client who complains of weight loss,
racing heart rate, and difficulty sleeping.The nurse determines the
A
client has moist skin with fine hair, prominent eyes, lid retraction,
and a staring expression. These findings are consistent with which
(This client is exhibiting symptoms associated with hyperthy-
disorder?
roidism or Grave's disease, which is an autoimmune condition
a. Grave's disease.
affecting the thyroid. Cushing syndrome, multiple sclerosis, or
b. Cushing syndrome.
Addison's disease are not associated with these symptoms.)
c. Multiple sclerosis.
d. Addison's disease.
C
Which information should the nurse give a client with chronic
(A client with CKD should restrict sodium and potassium dietary
kidney disease (CKD)?
intake, and salt substitutes usually contain potassium, so they
a. Restrict calcium-rich foods.
should avoid using them. Hypocalcemia is a complication of CKD
b. Obtain monthly B12 injections.
and calcium supplements are often needed. Anemia related to
c. Avoid salt substitutes.
CKD is treated with iron, folic acid, and erythropoietin, not B12
d. Increase daily intake of fiber.
injections. Although increasing fiber is a common dietary recom-
mendation, it not an essential part of client teaching for CKD.)
A young adult female arrives at the emergency department with a
black right eye and is bleeding from the left side of her head. She
reports that her boyfriend has been abusing her physically. The
nurse performs a history and physical examination. How should
the nurse document these findings? D
a. Client alleges that her boyfriend beat her up. Client is bleeding
from the left side of the face. (Proper documentation of abuse as reported by the victim is
b. Client reports her boyfriend hit her in the eye and on the head. crucial, and the nurse should document specific and objective data
Bruises and lacerations present on face. that gives an accurate depiction of the events without documenta-
c. Client presents with a right black eye and a cut on the left side of tion of judgmental inferences. All the other choices lack specificity
her head that is bleeding. Reports abusive boyfriend responsible and important details related to the event.)
for injuries. Needs referral to a safe place to stay.
d. Young adult female presents with periorbital ecchymosis on
right side, 3 cm laceration on left parietal area, approximately 1
cm deep with tissue bridging. States her boyfriend is abusive.
A retired office worker is admitted to the psychiatric inpatient unit B
with a diagnosis of major depression. The initial nursing care plan
includes the goal, "Assist client to express feelings of anger." (Depression is associated with feelings of anger, and clients are
Which nursing intervention is most important to include in the often not aware of these feelings. Awareness is the first step in
, HESI RN COMPREHENSIVE EXIT EXAM VERSION I- 75+ QUESTIONS AND
ANSWERS WITH RATIONALES|WELL STRUCTURED|A+ GRADED|
QUESTIONS ANSWERS
client's plan of care? dealing with anger (or any other feeling), so the nurse's efforts
a. Teach that anger will subside after two weeks on antidepres- should be directed toward increasing the client's awareness of
sants. feelings. Anger may persist after beginning antidepressant thera-
b. Ask client to describe triggers of anger. py, and it may not be necessary to revise the goal. Gathering data
c. Gather more data about social support. on social support systems can assist the client to cope, but it's
d. Collaborate with the treatment team about revising the goal. most important to ask the client to describe triggers of anger.)
C
The nurse determines that a client's body weight is 105% above (Obesity is a body weight that is 20% above desirable weight
the standardized height-weight scale. Which related factor should for a person's age, sex, height, body build, and calculated body
the nurse include in the nursing problem, "Imbalanced nutrition: mass index (BMI). Focusing on diet and exercise best identifies
more than body requirements?" factors that contribute to the formulation of the nursing diagnosis.
a. Morbidly obese. Markedly and morbid obesity are both medical classifications for
b. Markedly obese. a client's weight. Although the client is at an increased risk for
c. Inadequate lifestyle changes in diet and exercise. several chronic illnesses, such as heart disease, diabetes mellitus,
d. Increased morbidity and mortality risks. hypertension, coronary artery disease and hyperlipidemia, this is
not a contributing cause or related factor that supports the nursing
diagnosis.)
61
The formula for calculating daily fluid requirements is:
A child is receiving maintenance intravenous (IV) fluids at the rate
0 to 10 kg= 100 ml/kg per day;
of 1000 ml for the first 10 kg of body weight, plus 50 ml/kg per
day for each kilogram between 10 and 20. How many milliliters
10 to 20 kg = 1000 ml for the first 10 kg of body weight +50 ml/kg
per hour should the nurse program the infusion pump for a child
per day for each kilogram between 10 and 20.
who weighs 19.5 kg?
(Enter numeric value only. If rounding is required, round to the
To determine an hourly rate, divide the total milliliters per day by
nearest whole number.)
24.
19.5 kg x 50 ml/kg = 475 ml + 1000 ml = 1475 ml / 24 hours = 61
ml/hour
D
Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchy-
mosis behind the ear over the mastoid process are both signs of
a basilar skull fracture, so the nurse should assess for possible
meningeal tears that manifest as a Halo sign with CSF leakage
A 6-year-old child is alert but quiet when brought to the emergency
from the ears or nose. Asymmetry of the face is consistent with
center with periorbital ecchymosis and ecchymosis behind the
orbital fractures. Abnormal position of arms occurs with wrenching
ears. The nurse suspects potential child abuse and continues to
assess the child for additional manifestations of a basilar skull traumas of the shoulder or arm fractures. Vomiting blood occurs
fracture. What assessment finding would be consistent with a with blunt abdominal injuries.
basilar skull fracture?
a. Asymmetry of the face and eye movements.
b. Abnormal position and movement of the arm.
c. Hematemesis and abdominal distention.
d. Rhinorrhoea or otorrhoea with Halo sign
A
The nurse is assessing a client and identifies the presence of
petechiae. Which documentation best describes this finding? (Petechiae are described as purplish to red, non-blanchable, pin-
a. Purplish-red pinpoint lesions of the skin. point lesions that are tiny hemorrhages within the dermal or sub-
b. Purple to bluish discoloration of the skin. mucosal layers. Purplish skin discoloration describes ecchymosis
c. Small circumscribed elevations containing purulent fluid. caused by trauma to the underlying blood vessels. Small eleva-
d. Generalized reddish discoloration of an area of skin. tions containing pus describes pustules. Generalize red skin area
is nonspecific and incomplete.)
A client is receiving atenolol (Tenormin) 25 mg PO after a myocar-
dial infarction. The nurse determines the client's apical pulse is 65
ANSWERS WITH RATIONALES|WELL STRUCTURED|A+ GRADED|
QUESTIONS ANSWERS
D
The nurse is monitoring neurological vital signs for a male client
who lost consciousness after falling and hitting his head. Which (Neurological vital signs include serial assessments of TPR, blood
assessment finding is the earliest and most sensitive indication of
pressure, and components of the Glasgow coma scale (GCS),
altered cerebral function?
which includes verbal, musculoskeletal, and pupillary responses.
a. Unequal pupils.
A change in the client's level of consciousness, as indicated by
b. Loss of central reflexes.
responses to commands during the GCS, is the first and the most
c. Inability to open the eyes.
sensitive sign of change in cerebral function. The other assess-
d. Change in level of consciousness.
ment data choices are late signs of altered cerebral function.)
D
(A common genital tract infection in females is candidiasis, which
A nurse is planning to teach self-care measures to a female client is an overgrowth of the normal vaginal flora of Candida albi-
about prevention of yeast infections. Which instructions should the cans that thrives in an environment that is warm and moist and
nurse provide? is perpetuated by tight-fitting clothing, underwear, or pantyhose
a. Use a douche preparation no more than once a month. made of nonabsorbent materials. The client should wear clothing
b. Increase daily intake of fiber and leafy green vegetables. that is loose fitting and absorbent, such as cotton underwear,
c. Select nylon underwear that is loose-fitting, white, and comfort- and avoid using bubble-bath or bath salts which further irritate
able. sensitive genital tissue. Douching is not recommended because
d. Avoid tight-fitting clothing and do not use bubble-bath or bath it can irritate vaginal tissue, alter pH, and contribute to fungal
salts. growth. While increasing dietary fiber intake encourages healthy,
nutritional guidelines, it is not the focus of the teaching. Cotton, not
nylon undergarments, provide absorbancy and reduce moisture in
the perineal area.)
D
A client who has active tuberculosis (TB) is admitted to the med-
ical unit. What action is most important for the nurse to implement? (Active tuberculosis requires implementation of airborne precau-
tions, so the client should be assigned to a negative pressure
a. Place an isolation cart in the hallway. air-flow room. Although isolation gowns and isolation carts should
b. Fit the client with a respirator mask. be implemented for clients in isolation with contact precautions, it
c. Don a clean gown for client care. is most important that air flow from the room is minimized when the
d. Assign the client to a negative air-flow room. client has TB. The respirator mask should be implemented when
the client leaves the isolation environment.)
The nurse is planning to conduct nutritional assessments and diet
teaching to clients at a family health clinic. Which individual has A
the greatest nutritional and energy demands?
a. A pregnant woman. A pregnant woman's metabolic demands are 20 to 24% more than
b. A teenager beginning puberty. the basic metabolic rate. The other clients require only 15 to 20%
c. A 3-month-old infant. more than the basic metabolic rate.
d. A school-aged child.
B
(Primary nursing is a model of delivery of care where a nurse is
What nursing delivery of care provides the nurse to plan and direct
accountable for planning care for clients around the clock. Func-
care of a group of clients over a 24-hour period?
tional nursing is a care delivery model that provides client care by
a. Team nursing.
assignment of functions or tasks. Team nursing is a care delivery
b. Primary nursing.
model where assignments to a group of clients are provided by a
c. Case management.
mixed-staff team. Case management is the delivery of care that
d. Functional nursing.
uses a collaborative process of assessment, planning, facilitation,
and advocacy for options and services to meet an individual's
health needs and promote quality cost-effective outcomes.)
A
Which approach should the nurse use when preparing a toddler
(Imitation is one of the most distinguishing characteristics of tod-
for a procedure?
dler play, so demonstration of a procedure on a doll enables a
non-threatening, dramatic experience that can help prepare the
a. Demonstrate the procedure using a doll.
toddler for the actual procedure. The primary developmental task
b. Avoid asking the child to make choices.
in toddlerhood is acquiring a sense of autonomy, so giving choices
c. Plan a teaching session to last about 20 minutes.
whenever possible to a toddler is recommended, not avoiding
d. Show equipment but prevent child from handling it.
asking the toddler to make a choice. Since the toddler's attention
span is short, teaching sessions should be brief and can be
, HESI RN COMPREHENSIVE EXIT EXAM VERSION I- 75+ QUESTIONS AND
ANSWERS WITH RATIONALES|WELL STRUCTURED|A+ GRADED|
QUESTIONS ANSWERS
repeated for reinforcement. Showing the equipment before its use
helps relieve anxiety, but the child should be allowed to handle
some of the equipment to prevent frustration and alleviate fear.)
The nurse is caring for a client who is the daughter of a local
politician. When the nurse approaches a man who is reading the D
names on the hall doors, he identifies himself as a reporter for
the local newspaper and requests information about the client's (Confidentiality is the nurse's primary responsibility and is sup-
status. Which standard of nursing practice should the nurse use ported by HIPAA, which mandates that personal information is
to respond? not disclosed and access to sensitive client information is limited.
a. Caring. Caring involves the nurse's concern about how the client experi-
b. Veracity. ences the world. Veracity is the nurse's duty to tell the truth and not
c. Advocacy. deceive others. Advocacy is support of the client's best interests.)
d. Confidentiality.
A male client diagnosed with antisocial personality disorder is
morbidly obese and is placed on a low fat, low calorie diet. At D
dinner the nurse notes that he is trying to get other clients on the
unit to give him part of their meals. What intervention should the (The nurse should provide a reality check by helping the client
nurse implement? realize that there are consequences to his behavior. Removing
the client from the room or table does not help the client realize
a. Remove the client from the table and have him sit alone. that his behavior is manipulative and harmful to himself as well as
b. Send the client back to his room and do not allow him to eat. others. This behavior needs to be documented, but does not need
c. Report the behavior to the on-call psychologist immediately. to be reported immediately.)
d. Confront the client about the consequences of the behavior.
The nurse is assessing a client who complains of weight loss,
racing heart rate, and difficulty sleeping.The nurse determines the
A
client has moist skin with fine hair, prominent eyes, lid retraction,
and a staring expression. These findings are consistent with which
(This client is exhibiting symptoms associated with hyperthy-
disorder?
roidism or Grave's disease, which is an autoimmune condition
a. Grave's disease.
affecting the thyroid. Cushing syndrome, multiple sclerosis, or
b. Cushing syndrome.
Addison's disease are not associated with these symptoms.)
c. Multiple sclerosis.
d. Addison's disease.
C
Which information should the nurse give a client with chronic
(A client with CKD should restrict sodium and potassium dietary
kidney disease (CKD)?
intake, and salt substitutes usually contain potassium, so they
a. Restrict calcium-rich foods.
should avoid using them. Hypocalcemia is a complication of CKD
b. Obtain monthly B12 injections.
and calcium supplements are often needed. Anemia related to
c. Avoid salt substitutes.
CKD is treated with iron, folic acid, and erythropoietin, not B12
d. Increase daily intake of fiber.
injections. Although increasing fiber is a common dietary recom-
mendation, it not an essential part of client teaching for CKD.)
A young adult female arrives at the emergency department with a
black right eye and is bleeding from the left side of her head. She
reports that her boyfriend has been abusing her physically. The
nurse performs a history and physical examination. How should
the nurse document these findings? D
a. Client alleges that her boyfriend beat her up. Client is bleeding
from the left side of the face. (Proper documentation of abuse as reported by the victim is
b. Client reports her boyfriend hit her in the eye and on the head. crucial, and the nurse should document specific and objective data
Bruises and lacerations present on face. that gives an accurate depiction of the events without documenta-
c. Client presents with a right black eye and a cut on the left side of tion of judgmental inferences. All the other choices lack specificity
her head that is bleeding. Reports abusive boyfriend responsible and important details related to the event.)
for injuries. Needs referral to a safe place to stay.
d. Young adult female presents with periorbital ecchymosis on
right side, 3 cm laceration on left parietal area, approximately 1
cm deep with tissue bridging. States her boyfriend is abusive.
A retired office worker is admitted to the psychiatric inpatient unit B
with a diagnosis of major depression. The initial nursing care plan
includes the goal, "Assist client to express feelings of anger." (Depression is associated with feelings of anger, and clients are
Which nursing intervention is most important to include in the often not aware of these feelings. Awareness is the first step in
, HESI RN COMPREHENSIVE EXIT EXAM VERSION I- 75+ QUESTIONS AND
ANSWERS WITH RATIONALES|WELL STRUCTURED|A+ GRADED|
QUESTIONS ANSWERS
client's plan of care? dealing with anger (or any other feeling), so the nurse's efforts
a. Teach that anger will subside after two weeks on antidepres- should be directed toward increasing the client's awareness of
sants. feelings. Anger may persist after beginning antidepressant thera-
b. Ask client to describe triggers of anger. py, and it may not be necessary to revise the goal. Gathering data
c. Gather more data about social support. on social support systems can assist the client to cope, but it's
d. Collaborate with the treatment team about revising the goal. most important to ask the client to describe triggers of anger.)
C
The nurse determines that a client's body weight is 105% above (Obesity is a body weight that is 20% above desirable weight
the standardized height-weight scale. Which related factor should for a person's age, sex, height, body build, and calculated body
the nurse include in the nursing problem, "Imbalanced nutrition: mass index (BMI). Focusing on diet and exercise best identifies
more than body requirements?" factors that contribute to the formulation of the nursing diagnosis.
a. Morbidly obese. Markedly and morbid obesity are both medical classifications for
b. Markedly obese. a client's weight. Although the client is at an increased risk for
c. Inadequate lifestyle changes in diet and exercise. several chronic illnesses, such as heart disease, diabetes mellitus,
d. Increased morbidity and mortality risks. hypertension, coronary artery disease and hyperlipidemia, this is
not a contributing cause or related factor that supports the nursing
diagnosis.)
61
The formula for calculating daily fluid requirements is:
A child is receiving maintenance intravenous (IV) fluids at the rate
0 to 10 kg= 100 ml/kg per day;
of 1000 ml for the first 10 kg of body weight, plus 50 ml/kg per
day for each kilogram between 10 and 20. How many milliliters
10 to 20 kg = 1000 ml for the first 10 kg of body weight +50 ml/kg
per hour should the nurse program the infusion pump for a child
per day for each kilogram between 10 and 20.
who weighs 19.5 kg?
(Enter numeric value only. If rounding is required, round to the
To determine an hourly rate, divide the total milliliters per day by
nearest whole number.)
24.
19.5 kg x 50 ml/kg = 475 ml + 1000 ml = 1475 ml / 24 hours = 61
ml/hour
D
Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchy-
mosis behind the ear over the mastoid process are both signs of
a basilar skull fracture, so the nurse should assess for possible
meningeal tears that manifest as a Halo sign with CSF leakage
A 6-year-old child is alert but quiet when brought to the emergency
from the ears or nose. Asymmetry of the face is consistent with
center with periorbital ecchymosis and ecchymosis behind the
orbital fractures. Abnormal position of arms occurs with wrenching
ears. The nurse suspects potential child abuse and continues to
assess the child for additional manifestations of a basilar skull traumas of the shoulder or arm fractures. Vomiting blood occurs
fracture. What assessment finding would be consistent with a with blunt abdominal injuries.
basilar skull fracture?
a. Asymmetry of the face and eye movements.
b. Abnormal position and movement of the arm.
c. Hematemesis and abdominal distention.
d. Rhinorrhoea or otorrhoea with Halo sign
A
The nurse is assessing a client and identifies the presence of
petechiae. Which documentation best describes this finding? (Petechiae are described as purplish to red, non-blanchable, pin-
a. Purplish-red pinpoint lesions of the skin. point lesions that are tiny hemorrhages within the dermal or sub-
b. Purple to bluish discoloration of the skin. mucosal layers. Purplish skin discoloration describes ecchymosis
c. Small circumscribed elevations containing purulent fluid. caused by trauma to the underlying blood vessels. Small eleva-
d. Generalized reddish discoloration of an area of skin. tions containing pus describes pustules. Generalize red skin area
is nonspecific and incomplete.)
A client is receiving atenolol (Tenormin) 25 mg PO after a myocar-
dial infarction. The nurse determines the client's apical pulse is 65
