HESI 799 RN Exit Exam
A client on a long-term mental health unit repeatedly takes own pulse regardless of the
circumstance. What action should the nurse implement?
a. Overlook the client's behavior.
b. Distract client to interfere with the ritual.
c. Ask why the client checks the pulse.
d. Hold client's hand to stop the behavior. - ANSWERS-Overlook the client's behavior.
A client is discharged with automated peritoneal dialysis (PD) to be used nightly...which
instructions should the nurse include?
a. Wash hands before cleaning exit site
b. Keep the head of the bed flat at night
c. Feel for a thrill and a distal pulse nightly
d. Do not get up if fluid is left in the abdomen - ANSWERS-Wash hands before cleaning
exit site
Rationale: meticulous hand hygiene is essential when performing care for a peritoneal
dialysis, infections is a common complication of peritoneal dialysis.
The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation
for performing a sterile dressing change. Which action by the PN requires correction by
the charge nurse?
a- Opening the package
b- Picking up the second glove
c- Picking up the first glove
d- Positioning of the table - ANSWERS-Picking up the second glove
A young adult who is hit with a baseball bat on the temporal area of the left skull is
conscious when admitted to the ED and is transferred to the Neurological Unit to be
monitored for signs of closed head injury. Which assessment finding is indicative of a
developing epidural hematoma?
a. Altered consciousness within the first 24 hours after injury.
b. Cushing reflex and cerebral edema after 24 hours
c. Fever, nuchal rigidity and opisthotonos within hours
d. Headache and pupillary changes 48 hours after a head injury - ANSWERS-Altered
consciousness within the first 24 hours after injury.
A male client reports to the clinic nurse that he has been feeling well and is often "dizzy"
his blood pressure is elevated. Based on this findings, this client is at a greatest risk for
which pathophysiological condition?
a. Pulmonary hypertension
b. Left ventricular hypertrophy
,c. Renal failure
d. Stroke - ANSWERS-Stroke
The nurse ask the parent to stay during the examination of a male toddler's genital area.
Which intervention should the nurse implement?
a. Examine the genitalia as the last part of the total exam.
b. Use soothing statements to facilitate cooperation
c. Allow the child to keep underpants on to examine genitalia
d. Work slowly and methodically so not to stress the child - ANSWERS-Examine the
genitalia as the last part of the total exam.
Rationale: Examination of a child's genitalia is particularly stressful to toddles, so this
assessment is best left as the last part of the examination. A parent, not the nurse, best
does b. The genitals must be completely visualized and sometimes underwear for a
brief period of.
The nurse is changing a client's IV tubing and closing the roller clamp on the new tubing
setup when the solution bag is _____. Which action should the nurse take to ensure
adequate filling of the drip chamber?
a. Lower the IV bag to a flat surface
b. Compress the drip chamber
c. Open the roller clamp
d. Squeeze the bag of IV solution - ANSWERS-Compress the drip chamber
During an Insulin infusion for a client with diabetes mellitus who is experiencing
hyperglycemic hyperosmolar syndrome in addition to the client's glucose, which
laboratory value is most important for the nurse to monitor?
a. Urine ketones
b. Urine albumin
c. Serum protein
d. Serum potassium - ANSWERS-d. Serum potassium
Rationale: Electrolyte shifts are common during correction of hyperosmolar and
hyperglycemic states. Monitor electrolyte levels at least every 4 hours, or every 2 hours
if needed. Monitor serum sodium and potassium levels closely. If needed, use isotonic
and hypotonic saline solutions to adjust the patient's sodium level. Despite major
potassium loss during diuresis in early HHS stages, many patients initially present in a
hyperkalemic state due to dehydration. When fluid and insulin therapy begin, the serum
potassium level may drop dramatically.
In planning strategies to reduce a client's risk for complications following orthopedic
surgery, the nurse recognizes which pathology as the underlying cause of
osteomyelitis?
a. Infectious process
b. Metastatic process
c. Autoimmune disorder
, d. Inflammatory disorder - ANSWERS-infectious process
A client with a serum sodium level of 125 meq/mL should benefit most from the
administration of which intravenous solution?
a. 0.9% sodium chloride solution (normal saline)
b. 0.45% sodium chloride solution (half normal saline)
c. 10% Dextrose in 0.45% sodium chloride
d. 5% dextrose in 0.2% sodium chloride - ANSWERS-0.9% sodium chloride solution
(normal saline)
Rationale: Normal range = 135-145
A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three
times daily two months ago. Which finding provides the best indication that the
medication regimen is effective?
a. The nurse note that no pills remain in the prescription bottle.
b. The client serum Depakote level is 125 mcg/ml
c. The family reports a great reduction in client's maniac behavior
d. The client denies any occurrence of suicidal ideation. - ANSWERS-The family reports
a great reduction in client's maniac behavior
The nurse is triaging clients in an urgent care clinic. The client with which symptoms
should be referred to the health care provider immediately?
a. headache, photophobia, and nuchal rigidity
b. high fever, skin rash, and a productive cough
c. nausea, vomiting, and poor skin turgor
d. malaise, fever, and stiff, swollen joints - ANSWERS-headache, photophobia, and
nuchal rigidity
Rationale: Headache, photophobia, and nuchal rigidity are classic signs of meningeal
infection, so this client should immediately be referred to the health care provider. AC D
do not have priority of B
A client with Alzheimer's disease falls in the bathroom. The nurse notifies the charge
nurse and completes a fall follow-up assessment. What assessment finding warrants
immediate intervention by the nurse?
a. Urinary incontinence
b. Left forearm hematoma
c. Disorientation to surroundings
d. Dislodge intravenous site - ANSWERS-Left forearm hematoma
Rationale: The left forearm hematoma may be indicative an injury, such as broken
bone, that requires immediate intervention. A may be likely be due to the inability to use
the toilet due to the fall. Disorientation is a common symptom of Alzheimer's disease. IV
Dislodged is not an urgent concern.
A client on a long-term mental health unit repeatedly takes own pulse regardless of the
circumstance. What action should the nurse implement?
a. Overlook the client's behavior.
b. Distract client to interfere with the ritual.
c. Ask why the client checks the pulse.
d. Hold client's hand to stop the behavior. - ANSWERS-Overlook the client's behavior.
A client is discharged with automated peritoneal dialysis (PD) to be used nightly...which
instructions should the nurse include?
a. Wash hands before cleaning exit site
b. Keep the head of the bed flat at night
c. Feel for a thrill and a distal pulse nightly
d. Do not get up if fluid is left in the abdomen - ANSWERS-Wash hands before cleaning
exit site
Rationale: meticulous hand hygiene is essential when performing care for a peritoneal
dialysis, infections is a common complication of peritoneal dialysis.
The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation
for performing a sterile dressing change. Which action by the PN requires correction by
the charge nurse?
a- Opening the package
b- Picking up the second glove
c- Picking up the first glove
d- Positioning of the table - ANSWERS-Picking up the second glove
A young adult who is hit with a baseball bat on the temporal area of the left skull is
conscious when admitted to the ED and is transferred to the Neurological Unit to be
monitored for signs of closed head injury. Which assessment finding is indicative of a
developing epidural hematoma?
a. Altered consciousness within the first 24 hours after injury.
b. Cushing reflex and cerebral edema after 24 hours
c. Fever, nuchal rigidity and opisthotonos within hours
d. Headache and pupillary changes 48 hours after a head injury - ANSWERS-Altered
consciousness within the first 24 hours after injury.
A male client reports to the clinic nurse that he has been feeling well and is often "dizzy"
his blood pressure is elevated. Based on this findings, this client is at a greatest risk for
which pathophysiological condition?
a. Pulmonary hypertension
b. Left ventricular hypertrophy
,c. Renal failure
d. Stroke - ANSWERS-Stroke
The nurse ask the parent to stay during the examination of a male toddler's genital area.
Which intervention should the nurse implement?
a. Examine the genitalia as the last part of the total exam.
b. Use soothing statements to facilitate cooperation
c. Allow the child to keep underpants on to examine genitalia
d. Work slowly and methodically so not to stress the child - ANSWERS-Examine the
genitalia as the last part of the total exam.
Rationale: Examination of a child's genitalia is particularly stressful to toddles, so this
assessment is best left as the last part of the examination. A parent, not the nurse, best
does b. The genitals must be completely visualized and sometimes underwear for a
brief period of.
The nurse is changing a client's IV tubing and closing the roller clamp on the new tubing
setup when the solution bag is _____. Which action should the nurse take to ensure
adequate filling of the drip chamber?
a. Lower the IV bag to a flat surface
b. Compress the drip chamber
c. Open the roller clamp
d. Squeeze the bag of IV solution - ANSWERS-Compress the drip chamber
During an Insulin infusion for a client with diabetes mellitus who is experiencing
hyperglycemic hyperosmolar syndrome in addition to the client's glucose, which
laboratory value is most important for the nurse to monitor?
a. Urine ketones
b. Urine albumin
c. Serum protein
d. Serum potassium - ANSWERS-d. Serum potassium
Rationale: Electrolyte shifts are common during correction of hyperosmolar and
hyperglycemic states. Monitor electrolyte levels at least every 4 hours, or every 2 hours
if needed. Monitor serum sodium and potassium levels closely. If needed, use isotonic
and hypotonic saline solutions to adjust the patient's sodium level. Despite major
potassium loss during diuresis in early HHS stages, many patients initially present in a
hyperkalemic state due to dehydration. When fluid and insulin therapy begin, the serum
potassium level may drop dramatically.
In planning strategies to reduce a client's risk for complications following orthopedic
surgery, the nurse recognizes which pathology as the underlying cause of
osteomyelitis?
a. Infectious process
b. Metastatic process
c. Autoimmune disorder
, d. Inflammatory disorder - ANSWERS-infectious process
A client with a serum sodium level of 125 meq/mL should benefit most from the
administration of which intravenous solution?
a. 0.9% sodium chloride solution (normal saline)
b. 0.45% sodium chloride solution (half normal saline)
c. 10% Dextrose in 0.45% sodium chloride
d. 5% dextrose in 0.2% sodium chloride - ANSWERS-0.9% sodium chloride solution
(normal saline)
Rationale: Normal range = 135-145
A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three
times daily two months ago. Which finding provides the best indication that the
medication regimen is effective?
a. The nurse note that no pills remain in the prescription bottle.
b. The client serum Depakote level is 125 mcg/ml
c. The family reports a great reduction in client's maniac behavior
d. The client denies any occurrence of suicidal ideation. - ANSWERS-The family reports
a great reduction in client's maniac behavior
The nurse is triaging clients in an urgent care clinic. The client with which symptoms
should be referred to the health care provider immediately?
a. headache, photophobia, and nuchal rigidity
b. high fever, skin rash, and a productive cough
c. nausea, vomiting, and poor skin turgor
d. malaise, fever, and stiff, swollen joints - ANSWERS-headache, photophobia, and
nuchal rigidity
Rationale: Headache, photophobia, and nuchal rigidity are classic signs of meningeal
infection, so this client should immediately be referred to the health care provider. AC D
do not have priority of B
A client with Alzheimer's disease falls in the bathroom. The nurse notifies the charge
nurse and completes a fall follow-up assessment. What assessment finding warrants
immediate intervention by the nurse?
a. Urinary incontinence
b. Left forearm hematoma
c. Disorientation to surroundings
d. Dislodge intravenous site - ANSWERS-Left forearm hematoma
Rationale: The left forearm hematoma may be indicative an injury, such as broken
bone, that requires immediate intervention. A may be likely be due to the inability to use
the toilet due to the fall. Disorientation is a common symptom of Alzheimer's disease. IV
Dislodged is not an urgent concern.
