HESI EXIT EXAM Q & A WITH RATIONALES
CORRECT
1) The nurse enters the examination room of a client who has been told by her health care
provider that she has advanced ovarian cancer. Which response by the nurse is likely to be
most supportive for the client?
A. "I know many women who have survived ovarian
cancer."
B. "Let's talk about the treatments of ovarian
cancer."
C. "In my opinion I would suggest getting a second
opinion."
D. "Tell me about what you are feeling right now."
Rationale:
The most therapeutic action for the nurse is to be an active listener and to encourage the client
to explore her feelings. Giving false reassurance or personal suggestions are not therapeutic
communication for the client.
2) A nurse working in the emergency department admits a client with full-thickness burns to
50% of the body. Assessment findings indicate high-pitched wheezing, heart rate of 120
beats/min, and disorientation. Which action should the nurse take first?
A. Insert a large-bore IV for fluid resuscitation.
B. Prepare to assist with maintaining the airway.
C. Cleanse the wounds using sterile technique.
, HESI EXIT EXAM Q & A WITH RATIONALES
CORRECT
D. Administer an analgesic for pain.
Rationale:
High-pitched wheezing indicates laryngeal stridor, a sign of laryngeal edema associated with
lung injury. Airway management is the first priority of care. Options A, C, and D are all
appropriate interventions in managing the client with a burn but are not as critical as
establishing an airway.
3) The nurse walks into the room and observes the client experiencing a tonic- clonic
seizure. Which intervention should the nurse implement first?
A. Restrain the client to protect from injury.
B. Flex the neck to ensure stabilization.
C. Use a tongue blade to open the airway.
D. Turn client on the side to aid ventilation.
Rationale:
Maintaining the airway during a seizure is the priority for safety. Options A, B, and C are
contraindicated during a seizure and may cause further injury to the client.
4. A client tells the nurse that he is suffering from insomnia. Which information is most
important for the nurse to obtain?
A. The client's usual sleeping pattern
B. Whether the client smokes
C. How much liquid the client consumes before
bedtime
D. The amount of caffeine that the client consumes
during the day
Rationale:
The first thing to determine is the client's usual sleeping pattern and how it has changed to
CORRECT
1) The nurse enters the examination room of a client who has been told by her health care
provider that she has advanced ovarian cancer. Which response by the nurse is likely to be
most supportive for the client?
A. "I know many women who have survived ovarian
cancer."
B. "Let's talk about the treatments of ovarian
cancer."
C. "In my opinion I would suggest getting a second
opinion."
D. "Tell me about what you are feeling right now."
Rationale:
The most therapeutic action for the nurse is to be an active listener and to encourage the client
to explore her feelings. Giving false reassurance or personal suggestions are not therapeutic
communication for the client.
2) A nurse working in the emergency department admits a client with full-thickness burns to
50% of the body. Assessment findings indicate high-pitched wheezing, heart rate of 120
beats/min, and disorientation. Which action should the nurse take first?
A. Insert a large-bore IV for fluid resuscitation.
B. Prepare to assist with maintaining the airway.
C. Cleanse the wounds using sterile technique.
, HESI EXIT EXAM Q & A WITH RATIONALES
CORRECT
D. Administer an analgesic for pain.
Rationale:
High-pitched wheezing indicates laryngeal stridor, a sign of laryngeal edema associated with
lung injury. Airway management is the first priority of care. Options A, C, and D are all
appropriate interventions in managing the client with a burn but are not as critical as
establishing an airway.
3) The nurse walks into the room and observes the client experiencing a tonic- clonic
seizure. Which intervention should the nurse implement first?
A. Restrain the client to protect from injury.
B. Flex the neck to ensure stabilization.
C. Use a tongue blade to open the airway.
D. Turn client on the side to aid ventilation.
Rationale:
Maintaining the airway during a seizure is the priority for safety. Options A, B, and C are
contraindicated during a seizure and may cause further injury to the client.
4. A client tells the nurse that he is suffering from insomnia. Which information is most
important for the nurse to obtain?
A. The client's usual sleeping pattern
B. Whether the client smokes
C. How much liquid the client consumes before
bedtime
D. The amount of caffeine that the client consumes
during the day
Rationale:
The first thing to determine is the client's usual sleeping pattern and how it has changed to
