HESI 700 [2026/2027] Updated Version |
Verified Questions & Detailed Rationales
(GUARANTEED PASS)
The nurse is caring for a client who is experiencing severe pain. The
expected outcome the nurse writes for the client reads, "The client will
state my pain is less than 2 within 45 minutes after pain medication has
been administered." Formulating the expected outcome is an example of
which step in the nursing process?
A.Assessment
B.Planning
C.Implementation
D.Evaluation - VERIFIED ANSWER - B
Rationale:
Planning (B) allows the nurse to set goals for care and elicit the expected
outcome by identifying appropriate nursing actions. Assessment,
implementation, and evaluation are part of the care for the client but are
not the appropriate actions for formulating the expected outcome (A, C,
and D).
,The nurse is planning the care for a client who is admitted with syndrome
of inappropriate antidiuretic hormone secretion (SIADH). Which
intervention(s) should the nurse include in this client's plan of care?
(Select all that apply.)
A.Salt-free diet
B.Quiet environment
C.Deep tendon reflex assessments
D.Neurologic checks
E.Daily weights - VERIFIED ANSWER - B,C,D,E
Rationale:
Correct responses are (B, C, D, and E). SAIDH results in water retention
and dilutional hyponatremia, which causes neurologic changes when
serum sodium levels are less than 115 mEq/L. The nurse should maintain a
quiet environment (B) to prevent overstimulation and assess deep tendon
reflexes (C) and perform neurologic checks (D) to monitor for neurologic
deterioration. Daily weights (E) should be monitored to assess for fluid
overload. (A) would contribute to dilutional hyponatremia.
A client in the psychiatric setting with an anxiety disorder reports chest
pain. Which action should the nurse take first?
A.Administer an antianxiety medication PRN.
,B.Assess the client's vital signs.
C.Notify the primary health care provider.
D.Determine coping mechanisms used in the past. - VERIFIED ANSWER - B
Rationale:
Although increased heart rate, palpitations, and chest pain may be caused
by anxiety, it is important that the nurse assess the patient and rule out
physiologic causes (B). Nonpharmacologic measures should be taken first
(A). (C and D) may be considered but are not as high priority as the initial
physiologic assessment.
The charge nurse observes a student nurse enter the room of a client
who is prescribed airborne precautions. The application of which personal
protective equipment by the student indicates a correct understanding of
this precaution?
A.Surgical mask, clean gloves, and gown
B.Properly fitted N95 respirator or mask
C.Sterile gloves and gown
D.Goggles, clean gloves, and gown - VERIFIED ANSWER - B
Rationale:
The use of personal protective equipment (PPE) for airborne precautions
includes a properly prefitted N95 respirator or mask (B). (A, C and D) do
, not provide the appropriate respiratory equipment for airborne
precautions. A surgical mask is used for preventing transmission of
droplet precautions.
The nurse empties a client's urinary drainage from an indwelling Foley
catheter. Which finding should be reported to the primary health care
provider?
A.Ammonia odor is noted when the catheter is emptied.
B.240 mL of urinary output is produced in 12 hours.
C.A 16-French catheter was used for an adult female.
D.Drainage system is hanging below the level of the bladder. - VERIFIED
ANSWER - B
Rationale:
An expected finding is between 400 and 750 mL in 12 hours = average of
30 mL/hr (B). Ammonia odor is an expected finding (A). Size 14- to 18-
French catheters are common sizes used in the adult female (C). Below
the level of the bladder is the correct position for the drainage bag (D).
An adult female who presents at the mental clinic trembling and crying
becomes distressed when the nurse attempts to conduct an assessment.
She complains about the number of questions that are being asked, which
Verified Questions & Detailed Rationales
(GUARANTEED PASS)
The nurse is caring for a client who is experiencing severe pain. The
expected outcome the nurse writes for the client reads, "The client will
state my pain is less than 2 within 45 minutes after pain medication has
been administered." Formulating the expected outcome is an example of
which step in the nursing process?
A.Assessment
B.Planning
C.Implementation
D.Evaluation - VERIFIED ANSWER - B
Rationale:
Planning (B) allows the nurse to set goals for care and elicit the expected
outcome by identifying appropriate nursing actions. Assessment,
implementation, and evaluation are part of the care for the client but are
not the appropriate actions for formulating the expected outcome (A, C,
and D).
,The nurse is planning the care for a client who is admitted with syndrome
of inappropriate antidiuretic hormone secretion (SIADH). Which
intervention(s) should the nurse include in this client's plan of care?
(Select all that apply.)
A.Salt-free diet
B.Quiet environment
C.Deep tendon reflex assessments
D.Neurologic checks
E.Daily weights - VERIFIED ANSWER - B,C,D,E
Rationale:
Correct responses are (B, C, D, and E). SAIDH results in water retention
and dilutional hyponatremia, which causes neurologic changes when
serum sodium levels are less than 115 mEq/L. The nurse should maintain a
quiet environment (B) to prevent overstimulation and assess deep tendon
reflexes (C) and perform neurologic checks (D) to monitor for neurologic
deterioration. Daily weights (E) should be monitored to assess for fluid
overload. (A) would contribute to dilutional hyponatremia.
A client in the psychiatric setting with an anxiety disorder reports chest
pain. Which action should the nurse take first?
A.Administer an antianxiety medication PRN.
,B.Assess the client's vital signs.
C.Notify the primary health care provider.
D.Determine coping mechanisms used in the past. - VERIFIED ANSWER - B
Rationale:
Although increased heart rate, palpitations, and chest pain may be caused
by anxiety, it is important that the nurse assess the patient and rule out
physiologic causes (B). Nonpharmacologic measures should be taken first
(A). (C and D) may be considered but are not as high priority as the initial
physiologic assessment.
The charge nurse observes a student nurse enter the room of a client
who is prescribed airborne precautions. The application of which personal
protective equipment by the student indicates a correct understanding of
this precaution?
A.Surgical mask, clean gloves, and gown
B.Properly fitted N95 respirator or mask
C.Sterile gloves and gown
D.Goggles, clean gloves, and gown - VERIFIED ANSWER - B
Rationale:
The use of personal protective equipment (PPE) for airborne precautions
includes a properly prefitted N95 respirator or mask (B). (A, C and D) do
, not provide the appropriate respiratory equipment for airborne
precautions. A surgical mask is used for preventing transmission of
droplet precautions.
The nurse empties a client's urinary drainage from an indwelling Foley
catheter. Which finding should be reported to the primary health care
provider?
A.Ammonia odor is noted when the catheter is emptied.
B.240 mL of urinary output is produced in 12 hours.
C.A 16-French catheter was used for an adult female.
D.Drainage system is hanging below the level of the bladder. - VERIFIED
ANSWER - B
Rationale:
An expected finding is between 400 and 750 mL in 12 hours = average of
30 mL/hr (B). Ammonia odor is an expected finding (A). Size 14- to 18-
French catheters are common sizes used in the adult female (C). Below
the level of the bladder is the correct position for the drainage bag (D).
An adult female who presents at the mental clinic trembling and crying
becomes distressed when the nurse attempts to conduct an assessment.
She complains about the number of questions that are being asked, which
