HESI 799 RN EXIT EXAM 2026 NURSING
LICENSURE READINESS TEST PAPER
QUESTIONS AND SOLUTIONS GRADED A+
◉ Which assessment is more important for the nurse to include in
the daily plan of care for a client with a burned extremity
a. Range of Motion
b. Distal pulse intensity
c. Extremity sensation
d. Presence of exudate Answer: Distal pulse intensity
Rationale: Distal pulse intensity assesses the blood flow through the
extremity and is the most important assessment because it provides
information about adequate circulation to the extremity. Range of
motions evaluates the possibility of long term contractures
sensation. C evaluates neurological involvement, and exudate. D
provides information about wound infection, but this assessment
does not have the priority of determining perfusion to the extremity.
◉ An elderly client with degenerative joint disease asks if she should
use the rubber jar openers that are available. The nurse's response
should be based on which information about assistive devices?
,a. They can contribute to increased dependency
b. They decrease the risk for joint trauma
c. They promote muscle strength
d. They diminish range of motion ability. Answer: They decrease the
risk for joint trauma
Rationale: Assistive devices of this kind are very beneficial in
reducing joint trauma(B) caused by excessive twisting. These
devices promote independence, rather that increasing dependency
◉ When assessing a 6-month old infant, the nurse determines that
the anterior fontanel is bulging. In which situation would this
finding be most significant?
a. Crying
b. Straining on stool
c. Vomiting
d. Sitting upright. Answer: Sitting upright.
Rationale: The anterior fontanel closes at 9 months of age and may
bulge when venous return is reduced from the head, but a bulging
anterior fontanel is most significant if the infant is sitting up and
may indicated an increase in cerebrospinal fluid. Activities that
,reduce venous return from the head, such as crying, a Valsalva
maneuver, vomiting or a dependent position of the head, cause a
normal transient increase in intracranial pressure.
◉ A client with angina pectoris is being discharge from the hospital.
What instruction should the nurse plan to include in this discharge
teaching?
a. Engage in physical exercise immediately after eating to help
decrease cholesterol levels.
b. Walk briskly in cold weather to increase cardiac output
c. Keep nitroglycerin in a light-colored plastic bottle and readily
available.
d. Avoid all isometric exercises but walk regularly. Answer: Avoid all
isometric exercises, but walk regularly
Rationale: Isometric exercise can raise blood pressure for the
duration of the exercise, which may be dangerous for a client with
cardiovascular disease, while walking provides aerobic conditioning
that improves ling, blood vessel, and muscle function. Client with
angina should refrain from physical exercise for 2 hours after meals,
but exercising does not decrease cholesterol levels. Cold water cause
vasoconstriction that may cause chest pain. Nitroglycerin should be
readily available and stored in a dark-colored glass bottle not C, to
ensure freshness of the medication.
, ◉ What is the priority nursing action when initiating morphine
therapy via an intravenous patient-controlled analgesia (PCA)
pump?
a. Assess the client's ability to use a numeric pain scale
b. Initiate the dosage lockout mechanism on the PCA pump
c. Instruct the client to use the medication before the pain become
severe
d. Assess the abdomen for bowel sounds Answer: Initiate the dosage
lockout mechanism on the PCA pump
Rationale: Morphine depress respiration, so ensuring that the client
cannot overdose on the medications
◉ While undergoing hemodialysis, a male client suddenly complains
of dizziness. He is alert and oriented, but his skin is cool and clammy.
His vital signs are: heart rate 128 beats/minute, respirations 18
breaths per minute, and blood pressure 90/60. Which intervention
should the nurse implement first?
a. Raise the client's legs and feet
b. Administer 250 ml saline bolus
c. Decrease blood flow from dialyzer
LICENSURE READINESS TEST PAPER
QUESTIONS AND SOLUTIONS GRADED A+
◉ Which assessment is more important for the nurse to include in
the daily plan of care for a client with a burned extremity
a. Range of Motion
b. Distal pulse intensity
c. Extremity sensation
d. Presence of exudate Answer: Distal pulse intensity
Rationale: Distal pulse intensity assesses the blood flow through the
extremity and is the most important assessment because it provides
information about adequate circulation to the extremity. Range of
motions evaluates the possibility of long term contractures
sensation. C evaluates neurological involvement, and exudate. D
provides information about wound infection, but this assessment
does not have the priority of determining perfusion to the extremity.
◉ An elderly client with degenerative joint disease asks if she should
use the rubber jar openers that are available. The nurse's response
should be based on which information about assistive devices?
,a. They can contribute to increased dependency
b. They decrease the risk for joint trauma
c. They promote muscle strength
d. They diminish range of motion ability. Answer: They decrease the
risk for joint trauma
Rationale: Assistive devices of this kind are very beneficial in
reducing joint trauma(B) caused by excessive twisting. These
devices promote independence, rather that increasing dependency
◉ When assessing a 6-month old infant, the nurse determines that
the anterior fontanel is bulging. In which situation would this
finding be most significant?
a. Crying
b. Straining on stool
c. Vomiting
d. Sitting upright. Answer: Sitting upright.
Rationale: The anterior fontanel closes at 9 months of age and may
bulge when venous return is reduced from the head, but a bulging
anterior fontanel is most significant if the infant is sitting up and
may indicated an increase in cerebrospinal fluid. Activities that
,reduce venous return from the head, such as crying, a Valsalva
maneuver, vomiting or a dependent position of the head, cause a
normal transient increase in intracranial pressure.
◉ A client with angina pectoris is being discharge from the hospital.
What instruction should the nurse plan to include in this discharge
teaching?
a. Engage in physical exercise immediately after eating to help
decrease cholesterol levels.
b. Walk briskly in cold weather to increase cardiac output
c. Keep nitroglycerin in a light-colored plastic bottle and readily
available.
d. Avoid all isometric exercises but walk regularly. Answer: Avoid all
isometric exercises, but walk regularly
Rationale: Isometric exercise can raise blood pressure for the
duration of the exercise, which may be dangerous for a client with
cardiovascular disease, while walking provides aerobic conditioning
that improves ling, blood vessel, and muscle function. Client with
angina should refrain from physical exercise for 2 hours after meals,
but exercising does not decrease cholesterol levels. Cold water cause
vasoconstriction that may cause chest pain. Nitroglycerin should be
readily available and stored in a dark-colored glass bottle not C, to
ensure freshness of the medication.
, ◉ What is the priority nursing action when initiating morphine
therapy via an intravenous patient-controlled analgesia (PCA)
pump?
a. Assess the client's ability to use a numeric pain scale
b. Initiate the dosage lockout mechanism on the PCA pump
c. Instruct the client to use the medication before the pain become
severe
d. Assess the abdomen for bowel sounds Answer: Initiate the dosage
lockout mechanism on the PCA pump
Rationale: Morphine depress respiration, so ensuring that the client
cannot overdose on the medications
◉ While undergoing hemodialysis, a male client suddenly complains
of dizziness. He is alert and oriented, but his skin is cool and clammy.
His vital signs are: heart rate 128 beats/minute, respirations 18
breaths per minute, and blood pressure 90/60. Which intervention
should the nurse implement first?
a. Raise the client's legs and feet
b. Administer 250 ml saline bolus
c. Decrease blood flow from dialyzer
