HESI 799 RN Exit Exam Questions and
Answers A+ Guide
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
answers✅✅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
,HESI 799 RN Exit Exam Questions and
Answers A+ Guide
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 answers✅✅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)
,HESI 799 RN Exit Exam Questions and
Answers A+ Guide
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 answers✅✅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.
, HESI 799 RN Exit Exam Questions and
Answers A+ Guide
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
answers✅✅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 answers✅✅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.
Answers A+ Guide
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
answers✅✅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
,HESI 799 RN Exit Exam Questions and
Answers A+ Guide
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 answers✅✅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)
,HESI 799 RN Exit Exam Questions and
Answers A+ Guide
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 answers✅✅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.
, HESI 799 RN Exit Exam Questions and
Answers A+ Guide
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
answers✅✅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 answers✅✅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.
