HESI EXIT COMPREHENSIVE REVIEW A QUESTIONS & ANSWERS
1. The patient is being admitted to the neurological unit with a diagnosis of
stroke. When will the nurse begin discharge planning?
a. At the time of admission
b. The day before the patient is to be discharged
c. When outpatient therapy will no longer be needed
d. As soon as the patient’s discharge destination is known
ANS: A
Discharge planning begins when a patient enters the health care system. In
anticipation of the patient’s discharge from an institution, the nurse makes
appropriate referrals or consults a case manager or a discharge planner to
ensure that the patient’s needs are met at home. Referrals to home care or
outpatient therapy are often needed. Planning the day before discharge, when
outpatient therapy is no longer needed, and as soon as the discharge
destination is known is too late.
2. Which goal is most appropriate for a patient who has had a total hip
replacement?
The patient will ambulate briskly on the treadmill by the time of
a. discharge.
b. The patient will walk 100 feet using a walker by the time of discharge.
c. The nurse will assist the patient to ambulate in the hall 2 times a day.
d. The patient will ambulate by the time of discharge.
ANS: B
“The patient will walk 100 feet using a walker by the time of discharge” is
individualized, realistic, and measurable. “Ambulating briskly on a treadmill”
is not realistic for this patient. The option that focuses on the nurse, not the
patient, is not a measurable goal; this is an intervention. “The patient will
ambulate by the time of discharge” is not measurable because it does not
specify the distance. Even though we can see that the patient will ambulate,
this does not quantify how far. 1
3. The nurse is working on an orthopedic rehabilitation unit that requires
, lifting and positioning of patients. Which personal injury will the nurse
most likely try to prevent?
a. Arm
b. Hip
c. Back
d. Ankle
ANS: C
Back injuries are often the direct result of improper lifting and bending. The
most common back injury is strain on the lumbar muscle group. While arm,
hip, and ankle can occur, they are not as common as back.
4. A nurse is caring for a patient with osteoporosis and lactose intolerance.
What will the nurse do?
a. Encourage dairy products.
b. Monitor intake of vitamin D.
c. Increase intake of caffeinated drinks.
d. Try to do as much as possible for the patient.
ANS: B
Encourage patients at risk to be screened for osteoporosis and assess their
diets for calcium and vitamin D intake. Patients who have lactose
intolerance need dietary teaching about alternative sources of calcium.
Caffeine should be decreased. The goal of the patient with osteoporosis is
to maintain independence with ADLs. Assistive ambulatory devices,
adaptive clothing, and safety bars help the patient maintain independence.
5. A nurse is providing care to a group of patients. Which patient will the nurse
see first?
A patient with a hip replacement on prolonged bed rest reporting chest
a. pain and dyspnea
A bedridden patient who has a reddened area on the buttocks who
2
b. needs to be turned
A patient on bed rest who has renal calculi and needs to go to the
1. The patient is being admitted to the neurological unit with a diagnosis of
stroke. When will the nurse begin discharge planning?
a. At the time of admission
b. The day before the patient is to be discharged
c. When outpatient therapy will no longer be needed
d. As soon as the patient’s discharge destination is known
ANS: A
Discharge planning begins when a patient enters the health care system. In
anticipation of the patient’s discharge from an institution, the nurse makes
appropriate referrals or consults a case manager or a discharge planner to
ensure that the patient’s needs are met at home. Referrals to home care or
outpatient therapy are often needed. Planning the day before discharge, when
outpatient therapy is no longer needed, and as soon as the discharge
destination is known is too late.
2. Which goal is most appropriate for a patient who has had a total hip
replacement?
The patient will ambulate briskly on the treadmill by the time of
a. discharge.
b. The patient will walk 100 feet using a walker by the time of discharge.
c. The nurse will assist the patient to ambulate in the hall 2 times a day.
d. The patient will ambulate by the time of discharge.
ANS: B
“The patient will walk 100 feet using a walker by the time of discharge” is
individualized, realistic, and measurable. “Ambulating briskly on a treadmill”
is not realistic for this patient. The option that focuses on the nurse, not the
patient, is not a measurable goal; this is an intervention. “The patient will
ambulate by the time of discharge” is not measurable because it does not
specify the distance. Even though we can see that the patient will ambulate,
this does not quantify how far. 1
3. The nurse is working on an orthopedic rehabilitation unit that requires
, lifting and positioning of patients. Which personal injury will the nurse
most likely try to prevent?
a. Arm
b. Hip
c. Back
d. Ankle
ANS: C
Back injuries are often the direct result of improper lifting and bending. The
most common back injury is strain on the lumbar muscle group. While arm,
hip, and ankle can occur, they are not as common as back.
4. A nurse is caring for a patient with osteoporosis and lactose intolerance.
What will the nurse do?
a. Encourage dairy products.
b. Monitor intake of vitamin D.
c. Increase intake of caffeinated drinks.
d. Try to do as much as possible for the patient.
ANS: B
Encourage patients at risk to be screened for osteoporosis and assess their
diets for calcium and vitamin D intake. Patients who have lactose
intolerance need dietary teaching about alternative sources of calcium.
Caffeine should be decreased. The goal of the patient with osteoporosis is
to maintain independence with ADLs. Assistive ambulatory devices,
adaptive clothing, and safety bars help the patient maintain independence.
5. A nurse is providing care to a group of patients. Which patient will the nurse
see first?
A patient with a hip replacement on prolonged bed rest reporting chest
a. pain and dyspnea
A bedridden patient who has a reddened area on the buttocks who
2
b. needs to be turned
A patient on bed rest who has renal calculi and needs to go to the
