HESI EXIT EXAM (HESI III)
NEW COMPREHENSIVE REVIEW
QUESTIONS AND ANSWERS WITH
RATIONALES
1. A client has just returned from the post-anesthesia care unit (PACU) following a right
total knee arthroplasty. Which finding requires immediate action by the nurse?
A. The client rates pain as a 5 on a 0-10 scale.
B. The surgical dressing has a 4 cm area of bloody drainage.
C. The client's right great toe is cold to the touch and dusky in color.
D. The client's urine output over the last 2 hours is 75 mL.
Answer: C. Rationale: A cold, dusky toe on the operative leg indicates possible neurovascular
compromise (compartment syndrome or arterial occlusion). This is an emergency that requires
immediate notification of the surgeon to prevent permanent damage .
2. The nurse is assessing a client with Cushing's syndrome. Which physical finding is the
nurse most likely to observe?
A. Hyperpigmentation of the skin
B. Buffalo hump and moon face
C. Tremors and exophthalmos
D. Dry skin and brittle hair
,Answer: B. Rationale: Cushing's syndrome (excess cortisol) is characterized by central obesity,
moon face, buffalo hump, and purple striae. Hyperpigmentation is seen in Addison's disease.
Tremors and exophthalmos are seen in hyperthyroidism .
3. The nurse is caring for a client with a new diagnosis of Ménière's disease.
Which dietary modification should the nurse reinforce?
A. Low-sodium diet
B. High-fiber diet
C. Increased fluid intake
D. Low-potassium diet
Answer: A. Rationale: Ménière's disease is an inner ear disorder related to endolymphatic fluid
pressure. A low-sodium diet is recommended to help reduce fluid retention and decrease the
frequency and severity of vertigo attacks .
4. The nurse is providing care for a client with an above-the-knee amputation (AKA). The
client tells the nurse, "I feel like my foot is cramping." What is the best response by the
nurse?
A. "That is impossible because your foot is no longer there."
B. "You are experiencing phantom limb sensation, which is normal after this surgery."
C. "Let's focus on the healing of your leg, not on feelings that aren't real."
D. "I will call the doctor to get you a strong pain medication."
Answer: B. Rationale: Phantom limb sensation is a very common and normal phenomenon after
an amputation. Acknowledging the client's experience and providing a normalizing explanation
is the most therapeutic response .
5. The nurse is assessing the vital signs of a client who is 2 hours postpartum.
Which finding requires immediate follow-up?
, A. Temperature 100.2°F (37.9°C)
B. Heart rate 100 beats per minute
C. Respiratory rate 18 breaths per minute
D. Blood pressure 140/90 mm Hg
Answer: D. *Rationale: An elevated BP (140/90) in the immediate postpartum period could be a
sign of postpartum preeclampsia, a serious condition. This requires further assessment and
prompt notification of the provider .*
6. The nurse is administering a measles, mumps, and rubella (MMR) vaccine to a 12-
month-old child. The parent asks the nurse if there are any serious side effects to watch for.
Which response is most accurate?
A. "The most serious side effect is a high fever that can cause a seizure."
B. "Your child may develop a mild rash and fever in 7-10 days."
C. "There are no serious side effects; this is a very safe vaccine."
D. "Your child might get a mild case of the measles from the vaccine."
Answer: B. *Rationale: The MMR vaccine is a live, attenuated virus vaccine. It is common for
children to develop a mild, non-contagious rash and/or low-grade fever about a week to 10 days
after the vaccination as their body builds immunity .*
7. The nurse is caring for a client who is admitted with a diagnosis of bacterial meningitis.
Which personal protective equipment (PPE) should the nurse wear to enter the client's
room?
A. N95 respirator mask
B. Gown and gloves only
C. Surgical mask
D. No PPE is needed if the nurse has been vaccinated
NEW COMPREHENSIVE REVIEW
QUESTIONS AND ANSWERS WITH
RATIONALES
1. A client has just returned from the post-anesthesia care unit (PACU) following a right
total knee arthroplasty. Which finding requires immediate action by the nurse?
A. The client rates pain as a 5 on a 0-10 scale.
B. The surgical dressing has a 4 cm area of bloody drainage.
C. The client's right great toe is cold to the touch and dusky in color.
D. The client's urine output over the last 2 hours is 75 mL.
Answer: C. Rationale: A cold, dusky toe on the operative leg indicates possible neurovascular
compromise (compartment syndrome or arterial occlusion). This is an emergency that requires
immediate notification of the surgeon to prevent permanent damage .
2. The nurse is assessing a client with Cushing's syndrome. Which physical finding is the
nurse most likely to observe?
A. Hyperpigmentation of the skin
B. Buffalo hump and moon face
C. Tremors and exophthalmos
D. Dry skin and brittle hair
,Answer: B. Rationale: Cushing's syndrome (excess cortisol) is characterized by central obesity,
moon face, buffalo hump, and purple striae. Hyperpigmentation is seen in Addison's disease.
Tremors and exophthalmos are seen in hyperthyroidism .
3. The nurse is caring for a client with a new diagnosis of Ménière's disease.
Which dietary modification should the nurse reinforce?
A. Low-sodium diet
B. High-fiber diet
C. Increased fluid intake
D. Low-potassium diet
Answer: A. Rationale: Ménière's disease is an inner ear disorder related to endolymphatic fluid
pressure. A low-sodium diet is recommended to help reduce fluid retention and decrease the
frequency and severity of vertigo attacks .
4. The nurse is providing care for a client with an above-the-knee amputation (AKA). The
client tells the nurse, "I feel like my foot is cramping." What is the best response by the
nurse?
A. "That is impossible because your foot is no longer there."
B. "You are experiencing phantom limb sensation, which is normal after this surgery."
C. "Let's focus on the healing of your leg, not on feelings that aren't real."
D. "I will call the doctor to get you a strong pain medication."
Answer: B. Rationale: Phantom limb sensation is a very common and normal phenomenon after
an amputation. Acknowledging the client's experience and providing a normalizing explanation
is the most therapeutic response .
5. The nurse is assessing the vital signs of a client who is 2 hours postpartum.
Which finding requires immediate follow-up?
, A. Temperature 100.2°F (37.9°C)
B. Heart rate 100 beats per minute
C. Respiratory rate 18 breaths per minute
D. Blood pressure 140/90 mm Hg
Answer: D. *Rationale: An elevated BP (140/90) in the immediate postpartum period could be a
sign of postpartum preeclampsia, a serious condition. This requires further assessment and
prompt notification of the provider .*
6. The nurse is administering a measles, mumps, and rubella (MMR) vaccine to a 12-
month-old child. The parent asks the nurse if there are any serious side effects to watch for.
Which response is most accurate?
A. "The most serious side effect is a high fever that can cause a seizure."
B. "Your child may develop a mild rash and fever in 7-10 days."
C. "There are no serious side effects; this is a very safe vaccine."
D. "Your child might get a mild case of the measles from the vaccine."
Answer: B. *Rationale: The MMR vaccine is a live, attenuated virus vaccine. It is common for
children to develop a mild, non-contagious rash and/or low-grade fever about a week to 10 days
after the vaccination as their body builds immunity .*
7. The nurse is caring for a client who is admitted with a diagnosis of bacterial meningitis.
Which personal protective equipment (PPE) should the nurse wear to enter the client's
room?
A. N95 respirator mask
B. Gown and gloves only
C. Surgical mask
D. No PPE is needed if the nurse has been vaccinated
