INVESTIGATED HESI EXIT
QUESTIONS AND ANSWERS
The nurse performs a prescribed neurological check at the beginning of the shift on a client who was
admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow Coma Scale
(GCS) score is 9. What information is most important for the nurse to determine?
A. The client's previous GCS score
B. When the client's stroke symptoms started
C. If the client is oriented to time
D. The client's blood pressure and respiration raTe - CORRECT ANSWER -A
Rationale: The normal GCS is 15, and it is most important for the nurse to
determine if it abnormal score a sign of improvement or a deterioration in the
client's condition
Based on principles of asepsis, the nurse should consider which circumstance to be sterile?
• One inch- border around ythe yedge yof ythe ysterile yfield yset yup yin ythe yoperating yroom
• A ywrapped yunopened, ysterile y4x4 ygauze yplaced yon ya ydamp ytable ytop.
• An yopen ysterile yFoley ycatheter ykit yset yup yon ya ytable yat ythe ynurse ywaist ylevel
• Sterile ysyringe yis yplaced yon ysterile yarea yas ythe ynurse yriches yover ythe ysterile yfield. y- yCORRECT
yANSWER y-CyRationale: yA ysterile ypackage yat yor yabove ythe ywaist ylevel yis yconsidered ysterile. yThe
edge yof ysterile yfield yis ycontaminated ywhich yinclude ya y1-inch yborder y(A). yA
ysterile yobjects ybecome ycontaminated yby ycapillary yaction ywhen ysterile
yobjects ybecome yinycontact ywith ya ywet ycontaminated ysurface.
,An yunlicensed yassistive ypersonnel y(UAP) yreports ythat ya yclient's yright yhand yand yfingers
yspasms ywhen ytaking ythe yblood ypressure yusing ythe ysame yarm. yAfter yconfirming ythe
ypresence yof yspams ywhat yactionyshould ythe ynurse ytake?
• Ask ythe yUAP yto ytake ythe yblood ypressure yin ythe yother yarm
• Tell ythe yUAP yto yuse ya ydifferent ysphygmomanometer.
• Review ythe yclient's yserum ycalcium ylevel
• Administer yPRN yantianxiety ymedication. y- yCORRECT yANSWER y-C
Rationale: yTrousseau's ysign yis yindicated yby yspasms yin ythe ydistal
yportion yof yanyextremity ythat yis ybeing yused yto ymeasure yblood
ypressure yand yis ycaused yby yhypocalcemia y(normal ylevel y9.0-10.5
ymg/dl, yso yC yshould ybe yimplemented.
A y56-years-old yman yshares ywith ythe ynurse ythat yhe yis yhaving ydifficulty ymaking ydecision yabout
yterminatingylife ysupport yfor yhis ywife. yWhat yis ythe ybest yinitial yaction yby ythe ynurse?
• Provide yan yopportunity yfor yhim yto yclarify yhis yvalues yrelated yto ythe ydecision
• Encourage yhim yto yshare ymemories yabout yhis ylife ywith yhis ywife yand yfamily
• Advise yhim yto yseek yseveral yopinions ybefore ymaking ydecision
• Offer yto ycontact ythe yhospital ychaplain yor ysocial yworker yto yoffer ysupport. y- yCORRECT
yANSWER y-AyRationale: yWhen ya yclient yis yfaced ywith ya ydecisional yconflict, ythe ynurse
yshould yfirst
provide yopportunities yfor ythe yclient yto yclarify yvalues yimportant yin ythe
ydecision. yTheyrest ymay yalso ybe ybeneficial yonce ythe yclient yas yclarified ythe
yvalues ythat yare yimportant yto yhim yin ythe ydecision-making yprocess
A yclient yis ybeing ydischarged yhome yafter ybeing ytreated yfor yheart yfailure
y(HF). yWhatyinstruction yshould ythe ynurse yinclude yin ythis yclient's ydischarge
yteaching yplan?
• Weigh yevery ymorning
• Eat ya yhigh yprotein ydiet
,• Perform yrange yof ymotion yexercises
, • Limit yfluid yintake yto y1,500 yml ydaily y- yCORRECT yANSWER y-A
A ychild ywith yheart yfailure yis yreceiving ythe ydiuretic yfurosemide y(Lasix) yand yhas
yserum ypotassium ylevel y3.0 ymEq/L. yWhich yassessment yis ymost yimportant yfor ythe
ynurse yto yobtain?
• Cardiac yrhythm yand yheart yrate.
• Daily yintake yof yfoods yrich yin ypotassium.
• Hourly yurinary youtput
• Thirst yad yskin yturgor. y- yCORRECT yANSWER y-A
The ynurse ynote ya ydepressed yfemale yclient yhas ybeen ymore ywithdrawn yand ynon ycommunicative
yduring ytheypast ytwo yweeks. yWhich yintervention yis ymost yimportant yto
include yin ythe yupdated yplan yof ycare yfor ythis yclient?
• Encourage ythe yclient's yfamily yto yvisit ymore yoften
• Schedule ya ydaily yconference ywith ythe ysocial yworker
• Encourage ythe yclient yto yparticipate yin ygroup yactivities
• Engage ythe yclient yin ya ynon-threatening yconversation. y- yCORRECT yANSWER y-
D yRationale: yConsistent yattempts yto ydraw ythe yclient yinto yconversations ywhich
yfocus yonynon-threatening ysubjects ycan ybe yan yeffective ymeans yof yeliciting ya
yresponse, ythereby ydecreasing yisolation ybehaviors. yThere yis ynot ysufficient ydata
yto ysupport ythe yeffectiveness yof yA yas yan yintervention yfor ythis yclient.
yAlthough yB ymay ybe yindicated, ynursing yinterventions ycan yalso ybe yused yto
ytreat ythis yclient. yC yis ytoo ythreatening yto ythis yclient.
A yclient ywith yrheumatoid yarthritis y(RA) ystarts ya ynew yprescription yof yetanercept y(Enbrel)
ysubcutaneouslyyonce yweekly. yThe ynurse yshould yemphasize ythe yimportance yof
reporting yproblem yto ythe yhealthcare yprovider?
QUESTIONS AND ANSWERS
The nurse performs a prescribed neurological check at the beginning of the shift on a client who was
admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow Coma Scale
(GCS) score is 9. What information is most important for the nurse to determine?
A. The client's previous GCS score
B. When the client's stroke symptoms started
C. If the client is oriented to time
D. The client's blood pressure and respiration raTe - CORRECT ANSWER -A
Rationale: The normal GCS is 15, and it is most important for the nurse to
determine if it abnormal score a sign of improvement or a deterioration in the
client's condition
Based on principles of asepsis, the nurse should consider which circumstance to be sterile?
• One inch- border around ythe yedge yof ythe ysterile yfield yset yup yin ythe yoperating yroom
• A ywrapped yunopened, ysterile y4x4 ygauze yplaced yon ya ydamp ytable ytop.
• An yopen ysterile yFoley ycatheter ykit yset yup yon ya ytable yat ythe ynurse ywaist ylevel
• Sterile ysyringe yis yplaced yon ysterile yarea yas ythe ynurse yriches yover ythe ysterile yfield. y- yCORRECT
yANSWER y-CyRationale: yA ysterile ypackage yat yor yabove ythe ywaist ylevel yis yconsidered ysterile. yThe
edge yof ysterile yfield yis ycontaminated ywhich yinclude ya y1-inch yborder y(A). yA
ysterile yobjects ybecome ycontaminated yby ycapillary yaction ywhen ysterile
yobjects ybecome yinycontact ywith ya ywet ycontaminated ysurface.
,An yunlicensed yassistive ypersonnel y(UAP) yreports ythat ya yclient's yright yhand yand yfingers
yspasms ywhen ytaking ythe yblood ypressure yusing ythe ysame yarm. yAfter yconfirming ythe
ypresence yof yspams ywhat yactionyshould ythe ynurse ytake?
• Ask ythe yUAP yto ytake ythe yblood ypressure yin ythe yother yarm
• Tell ythe yUAP yto yuse ya ydifferent ysphygmomanometer.
• Review ythe yclient's yserum ycalcium ylevel
• Administer yPRN yantianxiety ymedication. y- yCORRECT yANSWER y-C
Rationale: yTrousseau's ysign yis yindicated yby yspasms yin ythe ydistal
yportion yof yanyextremity ythat yis ybeing yused yto ymeasure yblood
ypressure yand yis ycaused yby yhypocalcemia y(normal ylevel y9.0-10.5
ymg/dl, yso yC yshould ybe yimplemented.
A y56-years-old yman yshares ywith ythe ynurse ythat yhe yis yhaving ydifficulty ymaking ydecision yabout
yterminatingylife ysupport yfor yhis ywife. yWhat yis ythe ybest yinitial yaction yby ythe ynurse?
• Provide yan yopportunity yfor yhim yto yclarify yhis yvalues yrelated yto ythe ydecision
• Encourage yhim yto yshare ymemories yabout yhis ylife ywith yhis ywife yand yfamily
• Advise yhim yto yseek yseveral yopinions ybefore ymaking ydecision
• Offer yto ycontact ythe yhospital ychaplain yor ysocial yworker yto yoffer ysupport. y- yCORRECT
yANSWER y-AyRationale: yWhen ya yclient yis yfaced ywith ya ydecisional yconflict, ythe ynurse
yshould yfirst
provide yopportunities yfor ythe yclient yto yclarify yvalues yimportant yin ythe
ydecision. yTheyrest ymay yalso ybe ybeneficial yonce ythe yclient yas yclarified ythe
yvalues ythat yare yimportant yto yhim yin ythe ydecision-making yprocess
A yclient yis ybeing ydischarged yhome yafter ybeing ytreated yfor yheart yfailure
y(HF). yWhatyinstruction yshould ythe ynurse yinclude yin ythis yclient's ydischarge
yteaching yplan?
• Weigh yevery ymorning
• Eat ya yhigh yprotein ydiet
,• Perform yrange yof ymotion yexercises
, • Limit yfluid yintake yto y1,500 yml ydaily y- yCORRECT yANSWER y-A
A ychild ywith yheart yfailure yis yreceiving ythe ydiuretic yfurosemide y(Lasix) yand yhas
yserum ypotassium ylevel y3.0 ymEq/L. yWhich yassessment yis ymost yimportant yfor ythe
ynurse yto yobtain?
• Cardiac yrhythm yand yheart yrate.
• Daily yintake yof yfoods yrich yin ypotassium.
• Hourly yurinary youtput
• Thirst yad yskin yturgor. y- yCORRECT yANSWER y-A
The ynurse ynote ya ydepressed yfemale yclient yhas ybeen ymore ywithdrawn yand ynon ycommunicative
yduring ytheypast ytwo yweeks. yWhich yintervention yis ymost yimportant yto
include yin ythe yupdated yplan yof ycare yfor ythis yclient?
• Encourage ythe yclient's yfamily yto yvisit ymore yoften
• Schedule ya ydaily yconference ywith ythe ysocial yworker
• Encourage ythe yclient yto yparticipate yin ygroup yactivities
• Engage ythe yclient yin ya ynon-threatening yconversation. y- yCORRECT yANSWER y-
D yRationale: yConsistent yattempts yto ydraw ythe yclient yinto yconversations ywhich
yfocus yonynon-threatening ysubjects ycan ybe yan yeffective ymeans yof yeliciting ya
yresponse, ythereby ydecreasing yisolation ybehaviors. yThere yis ynot ysufficient ydata
yto ysupport ythe yeffectiveness yof yA yas yan yintervention yfor ythis yclient.
yAlthough yB ymay ybe yindicated, ynursing yinterventions ycan yalso ybe yused yto
ytreat ythis yclient. yC yis ytoo ythreatening yto ythis yclient.
A yclient ywith yrheumatoid yarthritis y(RA) ystarts ya ynew yprescription yof yetanercept y(Enbrel)
ysubcutaneouslyyonce yweekly. yThe ynurse yshould yemphasize ythe yimportance yof
reporting yproblem yto ythe yhealthcare yprovider?
