HESI Exit Exam 303 QUESTIONS WITH VERIFIED
ANSWERS
A male client with cancer is admired to the oncology unit and tells the nurse that he is in
the hospital for palliative care measures. The nurse notes that the client's admission
prescription include radiation
therapy. What action should the nurse implement? - ANSWER-Ask the client about his
expected goals for the hospitalization.
Rationale: Palliative care measures provide relief or control of symptoms, so it is
important for the nurse to determine the client's goals for symptom control while
receiving treatment in the hospital. Although home care is available the client may not
be legible for palliative care at home. Radiation therapy is an effective positive care
measure used to manage symptoms and would be appropriate unless the radiation
conflicts with the client goals.
A client with myasthenia Gravis (MG) is receiving immunosuppressive therapy. Review
recent laboratory test results show that the client's serum magnesium level has
decreased below the normal range. In
addition to contacting the healthcare provider, what nursing action is most important? -
ANSWER-Observe rhythm on telemetry monitor.
Rationale: If not treated a low little Serum magnesium level can affect myocardial
depolarization leading to a lethal arrhythmia, and the nurse should assess for
dysrhythmias before contacting the healthcare provider. Other choices are common in
MG but do not contribute the Safety risk of low magnesium levels.
While assessing a radial artery catheter, the client complains of numbness and pain
distal to the insertion site. What interventions should the nurse implement? - ANSWER-
Promptly remove the arterial catheter from the radial artery.
A client is admitted with an epidural hematoma that resulted from a skateboarding
accident. To differentiate the vascular source of the intracranial bleeding, which finding
should the nurse monitor? - ANSWER-Rapid onset of decreased level of
consciousness.
When preparing a client for discharge from the hospital following a cystectomy and a
urinary diversion to treat bladder cancer, which instruction is most important for the
nurse to include in the client's discharge teaching plan? - ANSWER-Report any signs of
cloudy urine output.
,After repositioning an immobile client, the nurse observes an area of hyperemia. To
assess for blanching, what action should the nurse take? - ANSWER-Apply light
pressure over the area.
The nurse enters a client's room and observes the client's wrist restraint secured as
seen in the picture. What action should the nurse take? - ANSWER-Reposition the
restraint tie onto the bedframe.
A female client with acute respiratory distress syndrome (ARDS) is chemically
paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2.
Which assessment finding warrants
immediate intervention by the nurse? - ANSWER-Diminished left lower lobe sounds
Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax,
which required
immediate chest tube insertion to re-inflate the lung.
The development of atherosclerosis is a process of sequential events. Arrange the
pathophysiological events in orders of occurrence. (Place the first event on top and the
last on the bottom) - ANSWER-Arterial endothelium injury causes inflammation
Macrophages consume low density lipoprotein (LDL), creating foam cells
Foam cells release growth factors for smooth muscle cells
Smooth muscle grows over fatty streaks creating fibrous plaques
Vessel narrowing results in ischemia
Following a motor vehicle collision, an adult female with a ruptured spleen and a blood
pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her
urine output is 25 ml/hour for the last two hours. What pathophysiological reason
supports the nurse's decision to report this finding to the healthcare provider? -
ANSWER-Oliguria signals tubular necrosis related to hypoperfusion
A nurse-manager is preparing the curricula for a class for charge nurses. A staffing
formula based on what data ensures quality client care and is most cost-effective? -
ANSWER-Skills of staff and client acuity
When performing postural drainage on a client with Chronic Obstructive Pulmonary
Disease (COPD), which approach should the nurse use? - ANSWER-Explain that the
client may be placed in five positions
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 that the client has most likely experience a Bell's palsy rather
than a stroke? - ANSWER-Inability to close the affected eye, raise brow, or smile
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? - ANSWER-Keeps the irrigating container less than 18 inches above the
stoma
The nurse should teach the client to observe which precaution while taking
dronedarone? - ANSWER-Avoid grapefruits and its juice
A client who sustained a head injury following an automobile collision is admitted to the
hospital. The nurse include 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? - ANSWER-Increased Glasgow coma scale score.
Nuchal rigidity and papilledema.
Confusion and papilledema
Periorbital ecchymosis.
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.
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? - ANSWER-Confirm the necessity for continued use of the CVC.
During an annual physical examination, an older woman's fasting blood sugar (FBS) is
determined 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)? - ANSWER-Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
A client who was admitted yesterday with severe dehydration is complaining of pain a
24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention
should the nurse implement first? - ANSWER-Stop the normal saline infusion.
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 the left leg while waiting for surgery. Which intervention is
most important for the nurse to include in this client's plan care? - ANSWER-Ensure
proper alignment of the leg in traction.
A client who had a right hip replacement 3 day ago is pale has diminished breath sound
over the 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 provider? - ANSWER-Reassess
readiness for SNF transfer.
, A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a
prescription for metformin (Glucophage) 500 mg PO twice daily. What information
should the nurse include in this client's teaching plan? (Select all that apply.) -
ANSWER-Recognize signs and symptoms of hypoglycemia.
Report persist polyuria to the healthcare provider.
Take Glucophage with the morning and evening meal.
The nurse is developing an educational program for older clients who are being
discharged with new antihypertensive medications. The nurse should ensure that the
educational materials include which
characteristics? Select all that apply - ANSWER-Written at a twelfth grade reading level
Contains a list with definitions of unfamiliar terms
Uses common words with few Syllables
Printed using a 12 point type font
Uses pictures to help illustrate complex ideas
Rationale: During the aging process older clients often experience sensory or cognitive
changes, such as
decreased visual or hearing acuity, slower thought or reasoning processes, and shorter
attention span.
Materials for this age group should include at least of terms, such as a medical
terminology that incline
may not know and use common words that expresses information clearly and simply.
Simple, attractive
pictures help hold the learner's attention. The reading level of material should be at the
4th to 5th grade
level. Materials should be printed using large font (18-point or higher), not the standard
12-point font.
During the admission assessment, the nurse auscultates heart sounds for a client with
no history of cardiovascular disease. Where should the nurse listen when assessing the
client's point of maximal
impulse (PMI) (Click the chosen location. To change, click on a new location) -
ANSWER-Left Fourth Intercostal Space
An older male adult resident of long-term care facility is hospitalized for a cardiac
catheterization that occurred yesterday. Since the procedure was conducted, the client
has become increasingly disoriented. The night shift nurse reports that he attempted to
remove the sandbag from his femoral artery multiple times during the night. What
actions should the nurse take? (Select all that apply.) - ANSWER-Notify the healthcare
provider of the client's change in mental status.
Include q2 hour's reorientation in the client's plan of care.
An older male comes to the clinic with a family member. When the nurse attempts to
take the client's health history, he does not respond to questions in a clear manner.
What action should the nurse
ANSWERS
A male client with cancer is admired to the oncology unit and tells the nurse that he is in
the hospital for palliative care measures. The nurse notes that the client's admission
prescription include radiation
therapy. What action should the nurse implement? - ANSWER-Ask the client about his
expected goals for the hospitalization.
Rationale: Palliative care measures provide relief or control of symptoms, so it is
important for the nurse to determine the client's goals for symptom control while
receiving treatment in the hospital. Although home care is available the client may not
be legible for palliative care at home. Radiation therapy is an effective positive care
measure used to manage symptoms and would be appropriate unless the radiation
conflicts with the client goals.
A client with myasthenia Gravis (MG) is receiving immunosuppressive therapy. Review
recent laboratory test results show that the client's serum magnesium level has
decreased below the normal range. In
addition to contacting the healthcare provider, what nursing action is most important? -
ANSWER-Observe rhythm on telemetry monitor.
Rationale: If not treated a low little Serum magnesium level can affect myocardial
depolarization leading to a lethal arrhythmia, and the nurse should assess for
dysrhythmias before contacting the healthcare provider. Other choices are common in
MG but do not contribute the Safety risk of low magnesium levels.
While assessing a radial artery catheter, the client complains of numbness and pain
distal to the insertion site. What interventions should the nurse implement? - ANSWER-
Promptly remove the arterial catheter from the radial artery.
A client is admitted with an epidural hematoma that resulted from a skateboarding
accident. To differentiate the vascular source of the intracranial bleeding, which finding
should the nurse monitor? - ANSWER-Rapid onset of decreased level of
consciousness.
When preparing a client for discharge from the hospital following a cystectomy and a
urinary diversion to treat bladder cancer, which instruction is most important for the
nurse to include in the client's discharge teaching plan? - ANSWER-Report any signs of
cloudy urine output.
,After repositioning an immobile client, the nurse observes an area of hyperemia. To
assess for blanching, what action should the nurse take? - ANSWER-Apply light
pressure over the area.
The nurse enters a client's room and observes the client's wrist restraint secured as
seen in the picture. What action should the nurse take? - ANSWER-Reposition the
restraint tie onto the bedframe.
A female client with acute respiratory distress syndrome (ARDS) is chemically
paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2.
Which assessment finding warrants
immediate intervention by the nurse? - ANSWER-Diminished left lower lobe sounds
Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax,
which required
immediate chest tube insertion to re-inflate the lung.
The development of atherosclerosis is a process of sequential events. Arrange the
pathophysiological events in orders of occurrence. (Place the first event on top and the
last on the bottom) - ANSWER-Arterial endothelium injury causes inflammation
Macrophages consume low density lipoprotein (LDL), creating foam cells
Foam cells release growth factors for smooth muscle cells
Smooth muscle grows over fatty streaks creating fibrous plaques
Vessel narrowing results in ischemia
Following a motor vehicle collision, an adult female with a ruptured spleen and a blood
pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her
urine output is 25 ml/hour for the last two hours. What pathophysiological reason
supports the nurse's decision to report this finding to the healthcare provider? -
ANSWER-Oliguria signals tubular necrosis related to hypoperfusion
A nurse-manager is preparing the curricula for a class for charge nurses. A staffing
formula based on what data ensures quality client care and is most cost-effective? -
ANSWER-Skills of staff and client acuity
When performing postural drainage on a client with Chronic Obstructive Pulmonary
Disease (COPD), which approach should the nurse use? - ANSWER-Explain that the
client may be placed in five positions
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 that the client has most likely experience a Bell's palsy rather
than a stroke? - ANSWER-Inability to close the affected eye, raise brow, or smile
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? - ANSWER-Keeps the irrigating container less than 18 inches above the
stoma
The nurse should teach the client to observe which precaution while taking
dronedarone? - ANSWER-Avoid grapefruits and its juice
A client who sustained a head injury following an automobile collision is admitted to the
hospital. The nurse include 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? - ANSWER-Increased Glasgow coma scale score.
Nuchal rigidity and papilledema.
Confusion and papilledema
Periorbital ecchymosis.
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.
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? - ANSWER-Confirm the necessity for continued use of the CVC.
During an annual physical examination, an older woman's fasting blood sugar (FBS) is
determined 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)? - ANSWER-Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
A client who was admitted yesterday with severe dehydration is complaining of pain a
24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention
should the nurse implement first? - ANSWER-Stop the normal saline infusion.
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 the left leg while waiting for surgery. Which intervention is
most important for the nurse to include in this client's plan care? - ANSWER-Ensure
proper alignment of the leg in traction.
A client who had a right hip replacement 3 day ago is pale has diminished breath sound
over the 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 provider? - ANSWER-Reassess
readiness for SNF transfer.
, A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a
prescription for metformin (Glucophage) 500 mg PO twice daily. What information
should the nurse include in this client's teaching plan? (Select all that apply.) -
ANSWER-Recognize signs and symptoms of hypoglycemia.
Report persist polyuria to the healthcare provider.
Take Glucophage with the morning and evening meal.
The nurse is developing an educational program for older clients who are being
discharged with new antihypertensive medications. The nurse should ensure that the
educational materials include which
characteristics? Select all that apply - ANSWER-Written at a twelfth grade reading level
Contains a list with definitions of unfamiliar terms
Uses common words with few Syllables
Printed using a 12 point type font
Uses pictures to help illustrate complex ideas
Rationale: During the aging process older clients often experience sensory or cognitive
changes, such as
decreased visual or hearing acuity, slower thought or reasoning processes, and shorter
attention span.
Materials for this age group should include at least of terms, such as a medical
terminology that incline
may not know and use common words that expresses information clearly and simply.
Simple, attractive
pictures help hold the learner's attention. The reading level of material should be at the
4th to 5th grade
level. Materials should be printed using large font (18-point or higher), not the standard
12-point font.
During the admission assessment, the nurse auscultates heart sounds for a client with
no history of cardiovascular disease. Where should the nurse listen when assessing the
client's point of maximal
impulse (PMI) (Click the chosen location. To change, click on a new location) -
ANSWER-Left Fourth Intercostal Space
An older male adult resident of long-term care facility is hospitalized for a cardiac
catheterization that occurred yesterday. Since the procedure was conducted, the client
has become increasingly disoriented. The night shift nurse reports that he attempted to
remove the sandbag from his femoral artery multiple times during the night. What
actions should the nurse take? (Select all that apply.) - ANSWER-Notify the healthcare
provider of the client's change in mental status.
Include q2 hour's reorientation in the client's plan of care.
An older male comes to the clinic with a family member. When the nurse attempts to
take the client's health history, he does not respond to questions in a clear manner.
What action should the nurse
