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RN HESI EXIT EXAM|| ACCURATE AND
FREQUENTLY TESTED QUESTIONS AND 100%
CORRECT ANSWERS WITH RATIONALES||
LATEST AND COMPLETE UPDATE WITH
EXPERT VERIFIED SOLUTIONS|| SURE PASS!!
The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-
based hand rub while leaving a client's room after taking vital signs. What action
should the nurse take?
A. Instruct the UAP to return to the client's room to perform handwashing
B. Supervise the UAP in the next client's room to evaluate hand hygiene
C. Remind the UAP to continue rubbing the hands together until they are dry
D. Advice the UAP to wear gloves when obtaining vital signs for all clients -
ANSWER: C. Remind the UAP to continue rubbing the hands together until they
are dry
To prevent medication errors by an older client who is sometimes confused, which
intervention by the home health nurse is likely to be most effective?
A. Have an alert family member administer medications
B. Encourage taking medications at the same times daily
C. Instruct the client to wear glasses when reading labels
D. Provide education both verbally and in written format - ANSWER: D. Provide
education both verbally and in written format
A male client who fell of a roof has right and left femur fractures and crushing
injuries to both ankles. he is supine with bilateral skin traction applied to the lower
extremities while awaiting surgery within the next 4 hours. When asked to evaluate
his pain on a scale of 1 to 10, he screams that it is 20. For the last 4 hours, he has
received morphine 2mg IV hourly. His vial signs are heart rate 130 beats/minute,
respirations 32 breaths/minute, blood pressure 180/90 mmHg. Which intervention i
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- ANSWER: D. Assess the extremities for signs of compartment syndrome q2
hours
The nurse is assessing a client who returns to the unit after a thoracentesis in the
procedure room. Which finding should the nurse report to the healthcare provider
immediately?
A. Diminished breath sounds over the trocar insertion site
B. Equal bilateral chest expansion
C. Scattered crackles unchanged from baseline
D. Respiratory rate of 22 breaths/minute - ANSWER: A. Diminished breath
sounds over the trocar insertion site
An adult client is admitted to the emergency department after falling from a ladder.
While waiting to have a computed tomography (CT) scan, the client requests
something for a severe headache. When the nurse offers a prescribed dose of
acetaminophen, the client asks for something stronger. Which intervention should
the nurse implement?
A. Assess client's pupils for their reaction to light
B. Request that the CT scan be done immediately
C. Review client's history for use of illicit drugs
D. Expla - ANSWER: D. Explain the reason for using only non-narcotics
When caring for a client with a traumatic brain injury (TBI) who had a craniotomy
for increased intracranial pressure (ICP), the nurse assesses the client using the
Glasgow coma scale (GCS) every 2 hours. For the past 8 hours the client's GCS
score has been 14. What does this GCS finding indicate about this client?
A. Rehabilitative prognosis is an expected full recovery
B. Risk for irreversible cerebral damage related to increased ICP
C. Insertion of an ICP monitoring device is necessary
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D. Neu - ANSWER: D. Neurologically stable without indications of an increased
ICP
A client with cirrhosis of the liver is admitted with complications related to end
stage liver disease. Which interventions should the nurse implement?
A. Report serum albumin and globulin levels
B. Provide diet low in phosphorus
C. Note signs of swelling and edema
D. Monitor abdominal girth
E. Increase oral fluid intake to 1,500 mL daily - ANSWER: A. Report serum
albumin and globulin levels
C. Note signs of swelling and edema
D. Monitor abdominal girth
The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus
and learns that the client has a current blood glucose level of 720 mg/dL. When
assessing the client, what is the priority?
A. Assess for signs of fluid volume deficit
B. Observe wound drainage characteristics
C. Measure the level of acute pain
D. Determine when the client last ate - ANSWER: A. Assess for signs of fluid
volume deficit
A male client tells the nurse that he is concerned that he may have a stomach ulcer,
because he is experiencing heartburn and dull gnawing pain that is relieved when
he eats. Which is the best response by the nurse?
A. Encourage the client to obtain a complete physical exam, since these symptoms
are consistent with an ulcer
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B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is
not relieved with food
C. Instruct the client that these mild symptoms can generally be co - ANSWER:
A. Encourage the client to obtain a complete physical exam, since these symptoms
are consistent with an ulcer
A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a nasogastric tube to suction and is receiving Lactated
Ringer's solution at 75 mL/hr IV. One hour after admission to the unit, the nurse
notes 300mL of blood in the suction canister, the client's heart rate is 155
beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the
findings to the surgeon, which action should the nurse implement first?
A. Measure and document the client's uri - ANSWER: D. Increase the infusion
rate of Lactated Ringer's solution
A heparin infusion is prescribed for a client who weighs 220 pounds. After
administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for
the heparin solution as 18 units/kg/hour. The available solution is Heparin Sodium
25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the
infusion pump to deliver how many mL/hour? - ANSWER: -1st: calculate the
weight = 220/2.2= 100kg
-Then calculate total dose in units = 18units x 100kg = 1800 units/hr
- 25000 units - in 250
1800 units ---in X ml
x = 1800 x 250/25000 =18 mL/hr
An adult male who fell 20 feet from the roof of his home has multiple injuries,
including a right pneumothorax. Chest tubes were inserted in the emergency
department prior to his transfer to the intensive care unit (ICU). The nurse notes
that the suction control chamber is bubbling at the -10cm H2O mark, which
fluctuation in the water seal, and over the past hour 75 mL of bright red blood is
RN HESI EXIT EXAM|| ACCURATE AND
FREQUENTLY TESTED QUESTIONS AND 100%
CORRECT ANSWERS WITH RATIONALES||
LATEST AND COMPLETE UPDATE WITH
EXPERT VERIFIED SOLUTIONS|| SURE PASS!!
The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-
based hand rub while leaving a client's room after taking vital signs. What action
should the nurse take?
A. Instruct the UAP to return to the client's room to perform handwashing
B. Supervise the UAP in the next client's room to evaluate hand hygiene
C. Remind the UAP to continue rubbing the hands together until they are dry
D. Advice the UAP to wear gloves when obtaining vital signs for all clients -
ANSWER: C. Remind the UAP to continue rubbing the hands together until they
are dry
To prevent medication errors by an older client who is sometimes confused, which
intervention by the home health nurse is likely to be most effective?
A. Have an alert family member administer medications
B. Encourage taking medications at the same times daily
C. Instruct the client to wear glasses when reading labels
D. Provide education both verbally and in written format - ANSWER: D. Provide
education both verbally and in written format
A male client who fell of a roof has right and left femur fractures and crushing
injuries to both ankles. he is supine with bilateral skin traction applied to the lower
extremities while awaiting surgery within the next 4 hours. When asked to evaluate
his pain on a scale of 1 to 10, he screams that it is 20. For the last 4 hours, he has
received morphine 2mg IV hourly. His vial signs are heart rate 130 beats/minute,
respirations 32 breaths/minute, blood pressure 180/90 mmHg. Which intervention i
,2|Page
- ANSWER: D. Assess the extremities for signs of compartment syndrome q2
hours
The nurse is assessing a client who returns to the unit after a thoracentesis in the
procedure room. Which finding should the nurse report to the healthcare provider
immediately?
A. Diminished breath sounds over the trocar insertion site
B. Equal bilateral chest expansion
C. Scattered crackles unchanged from baseline
D. Respiratory rate of 22 breaths/minute - ANSWER: A. Diminished breath
sounds over the trocar insertion site
An adult client is admitted to the emergency department after falling from a ladder.
While waiting to have a computed tomography (CT) scan, the client requests
something for a severe headache. When the nurse offers a prescribed dose of
acetaminophen, the client asks for something stronger. Which intervention should
the nurse implement?
A. Assess client's pupils for their reaction to light
B. Request that the CT scan be done immediately
C. Review client's history for use of illicit drugs
D. Expla - ANSWER: D. Explain the reason for using only non-narcotics
When caring for a client with a traumatic brain injury (TBI) who had a craniotomy
for increased intracranial pressure (ICP), the nurse assesses the client using the
Glasgow coma scale (GCS) every 2 hours. For the past 8 hours the client's GCS
score has been 14. What does this GCS finding indicate about this client?
A. Rehabilitative prognosis is an expected full recovery
B. Risk for irreversible cerebral damage related to increased ICP
C. Insertion of an ICP monitoring device is necessary
,3|Page
D. Neu - ANSWER: D. Neurologically stable without indications of an increased
ICP
A client with cirrhosis of the liver is admitted with complications related to end
stage liver disease. Which interventions should the nurse implement?
A. Report serum albumin and globulin levels
B. Provide diet low in phosphorus
C. Note signs of swelling and edema
D. Monitor abdominal girth
E. Increase oral fluid intake to 1,500 mL daily - ANSWER: A. Report serum
albumin and globulin levels
C. Note signs of swelling and edema
D. Monitor abdominal girth
The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus
and learns that the client has a current blood glucose level of 720 mg/dL. When
assessing the client, what is the priority?
A. Assess for signs of fluid volume deficit
B. Observe wound drainage characteristics
C. Measure the level of acute pain
D. Determine when the client last ate - ANSWER: A. Assess for signs of fluid
volume deficit
A male client tells the nurse that he is concerned that he may have a stomach ulcer,
because he is experiencing heartburn and dull gnawing pain that is relieved when
he eats. Which is the best response by the nurse?
A. Encourage the client to obtain a complete physical exam, since these symptoms
are consistent with an ulcer
, 4|Page
B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is
not relieved with food
C. Instruct the client that these mild symptoms can generally be co - ANSWER:
A. Encourage the client to obtain a complete physical exam, since these symptoms
are consistent with an ulcer
A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a nasogastric tube to suction and is receiving Lactated
Ringer's solution at 75 mL/hr IV. One hour after admission to the unit, the nurse
notes 300mL of blood in the suction canister, the client's heart rate is 155
beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the
findings to the surgeon, which action should the nurse implement first?
A. Measure and document the client's uri - ANSWER: D. Increase the infusion
rate of Lactated Ringer's solution
A heparin infusion is prescribed for a client who weighs 220 pounds. After
administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for
the heparin solution as 18 units/kg/hour. The available solution is Heparin Sodium
25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the
infusion pump to deliver how many mL/hour? - ANSWER: -1st: calculate the
weight = 220/2.2= 100kg
-Then calculate total dose in units = 18units x 100kg = 1800 units/hr
- 25000 units - in 250
1800 units ---in X ml
x = 1800 x 250/25000 =18 mL/hr
An adult male who fell 20 feet from the roof of his home has multiple injuries,
including a right pneumothorax. Chest tubes were inserted in the emergency
department prior to his transfer to the intensive care unit (ICU). The nurse notes
that the suction control chamber is bubbling at the -10cm H2O mark, which
fluctuation in the water seal, and over the past hour 75 mL of bright red blood is
