HESI 799 RN Exit Exam LATEST UPDATE
Following discharge teaching, a male client with Review with the client the need to avoid foods that are rich in milk and
cream duodenal ulcer tells the nurse the he will drink plenty of
dairy products, such as milk, to help coat and protect his Rationale: Diets rich in milk and cream stimulate gastric acid secretion and
should ulcer. What is the best follow-up action by the nurse? be avoided.
a.Remind the client that it is also important to switch
to decaffeinated coffee and tea.
b.Suggest that the client also plan to eat frequent
small meals to reduce discomfort
c. Review with the client the need to avoid foods that
are rich in milk and cream.
d.Reinforce this teaching by asking the client to list
a dairy food that he might select.
A male client with hypertension, who received new Stroke secondary to hemorrhage
antihypertensive prescriptions at his last visit returns to the
clinic two weeks later to evaluate his blood pressure (BP). Rationale: Stroke related to cerebral hemorrhage is major risk for
uncontrolled His BP is 158/106 and he admits that he has not been hypertension.
taking the prescribed medication because the drugs
make him "feel bad". In explaining the need for
hypertension control, the nurse should stress that an
elevated BP places the client at risk for which
pathophysiological condition?
a.Blindness secondary to cataracts
b.Acute kidney injury due to glomerular damage
c. Stroke secondary to hemorrhage
d.Heart block due to myocardial damage
,The nurse observes an unlicensed assistive personnel Instruct the UAP to obtain soft blankets to secure to the side rails instead
of (UAP) positioning a newly admitted client who has a pillows
seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails. What action Rationale: The nurse should instruct the UAP to pad the side rails with soft
blankest should the nurse implement? because the use of pillows could result in suffocation and would need to be
removed at the onset of the seizure. The nurse can delegate paddling the side
rails to the UAP
a.Ensure that the UAP has placed the pillows effectively
to protect the client.
b.Instruct the UAP to obtain soft blankets to secure to
the side rails instead of pillows.
c.Assume responsibility for placing the pillows while
the UAP completes another task.
d.Ask the UAP to use some of the pillows to prop the
client in a side lying position.
An adolescent with major depressive disorder has been Describes life without purpose
taking duloxetine (Cymbalta) for the past 12 days. Which
assessment finding requires immediate follow-up Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor
that is known to increase the risk of suicidal thinking in adolescents and young
a.Describes life without purpose adults with major depressive disorder. B, C and D are side effects
b.Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d.Exhibits an increase in sweating.
A 60-year-old female client with a positive family history Further evaluation involving surgery may be
needed of ovarian cancer has developed an abdominal mass and
is being evaluated for possible ovarian cancer. Her Rationale: An abdominal mass in a client with a family history for ovarian
cancer Papanicolau (Pap) smear results are negative. What should be evaluated carefully
information should the nurse include in the client's
teaching plan
a.Further evaluation involving surgery may be needed
b.A pelvic exam is also needed before cancer is
ruled out
c. Pap smear evaluation should be continued every
six month
d.One additional negative pap smear in six months
is needed.
A client who recently underwent a tracheostomy is being Teach tracheal suctioning
techniques prepared for discharge to home. Which instructions is
most important for the nurse to include in the discharge Rationale: Suctioning helps to clear secretions and maintain an open
airway, which plan? is critical.
a.Explain how to use communication tools.
b.Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d.Demonstrate how to clean tracheostomy site.
, In assessing an adult client with a partial rebreather mask, Document the assessment
data the nurse notes that the oxygen reservoir bag does not
deflate completely during inspiration and the client's Rational: reservoir bag should not deflate completely during inspiration and
the respiratory rate is 14 breaths / minute. What action should client's respiratory rate is within normal limits.
the nurse implement
a.Encourage the client to take deep breaths
b.Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d.Document the assessment data
During shift report, the central electrocardiogram (EKG)Respiratory apnea of 30 seconds
monitoring system alarms. Which client alarm should the
nurse investigate first? Rationale: The priority is the client whose alarm indicating respiratory apnea
that should be assessed first.
a.Respiratory apnea of 30 seconds
b.Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
d.Disconnected monitor signal for the last 6 minutes.
During a home visit, the nurse observed an elderly client Check the client for lacerations or
fractures with diabetes slip and fall. What action should the nurse
take first? Rationale: After the client falls, the nurse should immediately assess for
the possibility of injuries and provide first aid as needed
a.Give the client 4 ounces of orange juice
b.Call 911 to summon emergency assistance
c. Check the client for lacerations or fractures
d.Asses clients blood sugar level
At 0600 while admitting a woman for a schedule repeat Inform the anesthesia care
provider cesarean section (C-Section), the client tells the nurse
that she drank a cup a coffee at 0400 because she Rationale: Surgical preoperative instruction includes NPO after midnight the day
of wanted to avoid getting a headache. Which action should surgery to decrease the risk of aspiration should vomiting occur during
anesthesia. the nurse take first? While it is possible the C-section will be done on schedule or rescheduled for
later in the day, the anesthesia provider should be notified first.
a.Ensure preoperative lab results are available
b.Start prescribed IV with lactated Ringer's
c. Inform the anesthesia care provider
d.Contact the client's obstetrician.
After placing a stethoscope as seen in the picture, the Listen with the bell at the same
location nurse auscultates S1 and S2 heart sounds. To determine if
an S3 heart sound is present, what action should the Rationale: The nurse uses the bell of the stethoscope to hear low-pitched
sounds nurse take first such as S3 and S4. The nurse listens at the same site using the diaphragm the
diaphragm and bell before moving systematically to the next sites.
a.Side the stethoscope across the sternum.
b.Move the stethoscope to the mitral site
c. Listen with the bell at the same location
d.Observe the cardiac telemetry monitor
Following discharge teaching, a male client with Review with the client the need to avoid foods that are rich in milk and
cream duodenal ulcer tells the nurse the he will drink plenty of
dairy products, such as milk, to help coat and protect his Rationale: Diets rich in milk and cream stimulate gastric acid secretion and
should ulcer. What is the best follow-up action by the nurse? be avoided.
a.Remind the client that it is also important to switch
to decaffeinated coffee and tea.
b.Suggest that the client also plan to eat frequent
small meals to reduce discomfort
c. Review with the client the need to avoid foods that
are rich in milk and cream.
d.Reinforce this teaching by asking the client to list
a dairy food that he might select.
A male client with hypertension, who received new Stroke secondary to hemorrhage
antihypertensive prescriptions at his last visit returns to the
clinic two weeks later to evaluate his blood pressure (BP). Rationale: Stroke related to cerebral hemorrhage is major risk for
uncontrolled His BP is 158/106 and he admits that he has not been hypertension.
taking the prescribed medication because the drugs
make him "feel bad". In explaining the need for
hypertension control, the nurse should stress that an
elevated BP places the client at risk for which
pathophysiological condition?
a.Blindness secondary to cataracts
b.Acute kidney injury due to glomerular damage
c. Stroke secondary to hemorrhage
d.Heart block due to myocardial damage
,The nurse observes an unlicensed assistive personnel Instruct the UAP to obtain soft blankets to secure to the side rails instead
of (UAP) positioning a newly admitted client who has a pillows
seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails. What action Rationale: The nurse should instruct the UAP to pad the side rails with soft
blankest should the nurse implement? because the use of pillows could result in suffocation and would need to be
removed at the onset of the seizure. The nurse can delegate paddling the side
rails to the UAP
a.Ensure that the UAP has placed the pillows effectively
to protect the client.
b.Instruct the UAP to obtain soft blankets to secure to
the side rails instead of pillows.
c.Assume responsibility for placing the pillows while
the UAP completes another task.
d.Ask the UAP to use some of the pillows to prop the
client in a side lying position.
An adolescent with major depressive disorder has been Describes life without purpose
taking duloxetine (Cymbalta) for the past 12 days. Which
assessment finding requires immediate follow-up Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor
that is known to increase the risk of suicidal thinking in adolescents and young
a.Describes life without purpose adults with major depressive disorder. B, C and D are side effects
b.Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d.Exhibits an increase in sweating.
A 60-year-old female client with a positive family history Further evaluation involving surgery may be
needed of ovarian cancer has developed an abdominal mass and
is being evaluated for possible ovarian cancer. Her Rationale: An abdominal mass in a client with a family history for ovarian
cancer Papanicolau (Pap) smear results are negative. What should be evaluated carefully
information should the nurse include in the client's
teaching plan
a.Further evaluation involving surgery may be needed
b.A pelvic exam is also needed before cancer is
ruled out
c. Pap smear evaluation should be continued every
six month
d.One additional negative pap smear in six months
is needed.
A client who recently underwent a tracheostomy is being Teach tracheal suctioning
techniques prepared for discharge to home. Which instructions is
most important for the nurse to include in the discharge Rationale: Suctioning helps to clear secretions and maintain an open
airway, which plan? is critical.
a.Explain how to use communication tools.
b.Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d.Demonstrate how to clean tracheostomy site.
, In assessing an adult client with a partial rebreather mask, Document the assessment
data the nurse notes that the oxygen reservoir bag does not
deflate completely during inspiration and the client's Rational: reservoir bag should not deflate completely during inspiration and
the respiratory rate is 14 breaths / minute. What action should client's respiratory rate is within normal limits.
the nurse implement
a.Encourage the client to take deep breaths
b.Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d.Document the assessment data
During shift report, the central electrocardiogram (EKG)Respiratory apnea of 30 seconds
monitoring system alarms. Which client alarm should the
nurse investigate first? Rationale: The priority is the client whose alarm indicating respiratory apnea
that should be assessed first.
a.Respiratory apnea of 30 seconds
b.Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
d.Disconnected monitor signal for the last 6 minutes.
During a home visit, the nurse observed an elderly client Check the client for lacerations or
fractures with diabetes slip and fall. What action should the nurse
take first? Rationale: After the client falls, the nurse should immediately assess for
the possibility of injuries and provide first aid as needed
a.Give the client 4 ounces of orange juice
b.Call 911 to summon emergency assistance
c. Check the client for lacerations or fractures
d.Asses clients blood sugar level
At 0600 while admitting a woman for a schedule repeat Inform the anesthesia care
provider cesarean section (C-Section), the client tells the nurse
that she drank a cup a coffee at 0400 because she Rationale: Surgical preoperative instruction includes NPO after midnight the day
of wanted to avoid getting a headache. Which action should surgery to decrease the risk of aspiration should vomiting occur during
anesthesia. the nurse take first? While it is possible the C-section will be done on schedule or rescheduled for
later in the day, the anesthesia provider should be notified first.
a.Ensure preoperative lab results are available
b.Start prescribed IV with lactated Ringer's
c. Inform the anesthesia care provider
d.Contact the client's obstetrician.
After placing a stethoscope as seen in the picture, the Listen with the bell at the same
location nurse auscultates S1 and S2 heart sounds. To determine if
an S3 heart sound is present, what action should the Rationale: The nurse uses the bell of the stethoscope to hear low-pitched
sounds nurse take first such as S3 and S4. The nurse listens at the same site using the diaphragm the
diaphragm and bell before moving systematically to the next sites.
a.Side the stethoscope across the sternum.
b.Move the stethoscope to the mitral site
c. Listen with the bell at the same location
d.Observe the cardiac telemetry monitor
