HESI 799 RN Exit Exam (101-200) LATEST UPDATE 2024/2025 HESI EXIT
COMPREHENSIVE REVIEW B (Q& As) COMPLETE RATIONALE GRADED A+
1. A client presents in the emergency room with right-sided facial asymmetry.
The nurse asks the client to perform a series of movements that require use
of the facial muscles. What symptoms suggest that the client has most likely
experience a Bell's palsy rather than a stroke?
a. Slow onset of facial drooping associated with headache
b. Inability to close the affected eye, raise brow, or smile
c. A flat nasolabial fold on the right resulting in facial asymmetry.
d. Drooling is present on right side of the mouth, but not on the left.: Inability
to close the affected eye, raise brow, or smile
Rationale: Because the motor function controlling eye closure, brow movement and
smiling are all carried on the 7th cranial (facial) nerve, the combination of symptoms
directly relating to an impairment of all branches of the facial nerve indicate that
Bell's palsy has occurred.
2. The nurse is teaching a client how to perform colostomy irrigations. When
observing the client's return demonstration, which action indicated that the
client understood the teaching?
a. Turns to left the side to instill the irrigating solution into the stoma
b. Keeps the irrigating container less than 18 inches above the stoma
c. Instills 1,200 ml of irrigating solution to stimulate bowel evacuation
d. Inserts irrigating catheter deeper into stoma when cramping occurs: Keeps
the irrigating container less than 18 inches above the stoma
Rationale: Keeping the irrigating container less than 18 inches above the stoma
permits the solution to flow slowly with little excessive peristalsis does not cause
immediate release of stool.
3. The nurse should teach the client to observe which precaution while taking
dronedarone?
a. Stay out of direct sunlight
b. Avoid grapefruits and its juice
c. Reduce the use of herbal supplements
d. Minimize sodium intake.: b. Avoid grapefruits and its juice
Rationale: Grapefruit increase the effect of dronedarone thereby increasing the
possibility of serious side effects. A does not cause a serious effect. C may potentiate
, HESI 799 RN Exit Exam (101-200) LATEST UPDATE 2024/2025 HESI EXIT
COMPREHENSIVE REVIEW B (Q& As) COMPLETE RATIONALE GRADED A+
lethal arrhythmias and should be avoided. D does not directly affect those taking
dronedarone.
4. A client who sustained a head injury following an automobile collision is
admitted to the hospital. The nurse include the client's risk for developing
increased intracranial pressure (ICP) in the plan of care. Which signs indicate
to the nurse that ICP has increased?
a. Increased Glasgow coma scale score.
b. Nuchal rigidity and papilledema.
c. Confusion and papilledema
d. Periorbital ecchymosis.: Confusion and papilledema
Rationale: papilledema is always an indicator of increased ICP, and confusion is
usually the first sign of increased ICP. Other options do not necessarily reflect
increased ICP.
5. The nurse is caring for a client receiving continuous IV fluids through a
single lumen central venous catheter (CVC). Based on the CVC care bundle,
which action should be completed daily to reduce the risk for infection?
a. Remind staff to follow protective environment precautions
b. Gently flush the catheter lumen with sterile saline solution
c. Cleanse the site and change the transparent dressing.
d. Confirm the necessity for continued use of the CVC.: Confirm the necessity
for continued use of the CVC
Rationale: Increase the length of use increase the risk for infection. The CVC care
bundle includes the review of the need for continued use of the CVC. Effective hand
hygiene and standard precautions should be maintained but protective environment
precautions are not needed. B is not needed if continuous IV fluid are infused, ad
may introduce contaminants. Use of a transparent dressing allows the site to be
visualized for any signs of infection but changing the dressing daily increases the
risk for infection.
6. During an annual physical examination, an older woman's fasting blood
sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional
finding obtained during a follow-up visit 2 weeks later is most indicative that
the client has diabetes mellitus (DM)?
a. An increased thirst with frequent urination
b. Blood glucose range during past two weeks was 110 to 125 mg/dl or 6.1 to
, HESI 799 RN Exit Exam (101-200) LATEST UPDATE 2024/2025 HESI EXIT
COMPREHENSIVE REVIEW B (Q& As) COMPLETE RATIONALE GRADED A+
7.0 mmol/L(SI)
c. Two-hour postprandial glucose tolerance test (GTT) is 160 mg/dL or 8.9
mmol/L (SI)
d. Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).: Repeat-
ed fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
7. A new mother tells the nurse that she is unsure if she will be able to
transition into parenthood. What action should the nurse take?
a. Provide reassurance to the client that these feeling are normal after delivery
b. Discuss delaying the client's discharge from the hospital for another 24 hrs.
c. Determine if she can ask for support from family, friend, or the baby's father.
d. Explain the differences between postpartum blues and postpartum depres-
sion.: Determine if she can ask for support from family, friend, or the baby's father
Rationale: Emotional support of significant family and friends can help a new mother
cope with anxiety about transitioning to parenthood. The nurse should ask the client
who is available to support her.
8. A client who was admitted yesterday with severe dehydration is complain-
ing of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour.
Which intervention should the nurse implement first?
a. Establish the second IV site
b. Asses the IV for blood return
c. Stop the normal saline infusion.
d. Discontinue the 24-gauge IV: Stop the normal saline infusion.
Rationale: If the IV has infiltrated or become dislodges, the fluid is infusing into
surrounding tissue and not into the vein. Stopping the infusion C is the priority action.
Establishing another IV site is necessary for fluid resuscitation after the infiltrated
infusion is discontinuing the IV (D) is necessary due to the pain, and a large gauge
needle is preferable.
9. An elderly female is admitted because of a change in her level of sensorium.
During the evening shift, the client attempts to get out bed and falls, breaking
her left hip. Buck's skin traction is applied to the left leg while waiting for
surgery. Which intervention is most important for the nurse to include in this
client's plan care?
a. Evaluate her response to narcotic analgesia
b. Asses the skin under the traction moleskin
, HESI 799 RN Exit Exam (101-200) LATEST UPDATE 2024/2025 HESI EXIT
COMPREHENSIVE REVIEW B (Q& As) COMPLETE RATIONALE GRADED A+
c. Place a pillow under the involved lower left leg
d. Ensure proper alignment of the leg in traction.: Ensure proper alignment of
the leg in traction.
Rationale: A fractured hip results in external rotation and shortening of the affected
extremity. With the application of Buck's skin traction proper alignment ensures the
transaction
S pull is exerted to align the fracture hip with the distal leg, immobilize the fractured
bone, and minimize muscle spasms and surrounding tissue injury related to the
fracture. A should be implement but improper pull of traction can increase pain and
soft tissue damage. B and C should be implemented but the greatest risk is improper
alignment of the traction.
10. An Unna boot is applied to a client with a venous stasis ulcer. One week
later, when the Unna boot is removed during a follow-up appointment, the
nurse observes that the ulcer site contains bright red tissue. What action
should the nurse take in response to this finding?
a. Immediately apply a pressure dressing
b. Document the ongoing wound healing.
c. Irrigate the wound with sterile saline
d. Obtain a capillary INR, measurement: Document the ongoing wound healing
Rationale: Appearance of granulation tissue is the best indicator of increased venous
retuns and ongoing wound healing
11. At the end of a preoperative teaching session on pain management tech-
niques, a client starts to cry and states, "I just know I can't handle all the pain."
What is the priority nursing diagnosis for this client?
a. Knowledge deficit
b. Anxiety
c. Anticipatory grieving
d. Pain (acute): anxiety
Rationale: The client is demonstrating only anxiety. There is no indication that the
client is presenting signs of A, C or D
12. The nurse note a visible prolapse of the umbilical cord after a client experi-
ences spontaneous rupture of the membranes during labor. What intervention
should the nurse implement immediately?
COMPREHENSIVE REVIEW B (Q& As) COMPLETE RATIONALE GRADED A+
1. A client presents in the emergency room with right-sided facial asymmetry.
The nurse asks the client to perform a series of movements that require use
of the facial muscles. What symptoms suggest that the client has most likely
experience a Bell's palsy rather than a stroke?
a. Slow onset of facial drooping associated with headache
b. Inability to close the affected eye, raise brow, or smile
c. A flat nasolabial fold on the right resulting in facial asymmetry.
d. Drooling is present on right side of the mouth, but not on the left.: Inability
to close the affected eye, raise brow, or smile
Rationale: Because the motor function controlling eye closure, brow movement and
smiling are all carried on the 7th cranial (facial) nerve, the combination of symptoms
directly relating to an impairment of all branches of the facial nerve indicate that
Bell's palsy has occurred.
2. The nurse is teaching a client how to perform colostomy irrigations. When
observing the client's return demonstration, which action indicated that the
client understood the teaching?
a. Turns to left the side to instill the irrigating solution into the stoma
b. Keeps the irrigating container less than 18 inches above the stoma
c. Instills 1,200 ml of irrigating solution to stimulate bowel evacuation
d. Inserts irrigating catheter deeper into stoma when cramping occurs: Keeps
the irrigating container less than 18 inches above the stoma
Rationale: Keeping the irrigating container less than 18 inches above the stoma
permits the solution to flow slowly with little excessive peristalsis does not cause
immediate release of stool.
3. The nurse should teach the client to observe which precaution while taking
dronedarone?
a. Stay out of direct sunlight
b. Avoid grapefruits and its juice
c. Reduce the use of herbal supplements
d. Minimize sodium intake.: b. Avoid grapefruits and its juice
Rationale: Grapefruit increase the effect of dronedarone thereby increasing the
possibility of serious side effects. A does not cause a serious effect. C may potentiate
, HESI 799 RN Exit Exam (101-200) LATEST UPDATE 2024/2025 HESI EXIT
COMPREHENSIVE REVIEW B (Q& As) COMPLETE RATIONALE GRADED A+
lethal arrhythmias and should be avoided. D does not directly affect those taking
dronedarone.
4. A client who sustained a head injury following an automobile collision is
admitted to the hospital. The nurse include the client's risk for developing
increased intracranial pressure (ICP) in the plan of care. Which signs indicate
to the nurse that ICP has increased?
a. Increased Glasgow coma scale score.
b. Nuchal rigidity and papilledema.
c. Confusion and papilledema
d. Periorbital ecchymosis.: Confusion and papilledema
Rationale: papilledema is always an indicator of increased ICP, and confusion is
usually the first sign of increased ICP. Other options do not necessarily reflect
increased ICP.
5. The nurse is caring for a client receiving continuous IV fluids through a
single lumen central venous catheter (CVC). Based on the CVC care bundle,
which action should be completed daily to reduce the risk for infection?
a. Remind staff to follow protective environment precautions
b. Gently flush the catheter lumen with sterile saline solution
c. Cleanse the site and change the transparent dressing.
d. Confirm the necessity for continued use of the CVC.: Confirm the necessity
for continued use of the CVC
Rationale: Increase the length of use increase the risk for infection. The CVC care
bundle includes the review of the need for continued use of the CVC. Effective hand
hygiene and standard precautions should be maintained but protective environment
precautions are not needed. B is not needed if continuous IV fluid are infused, ad
may introduce contaminants. Use of a transparent dressing allows the site to be
visualized for any signs of infection but changing the dressing daily increases the
risk for infection.
6. During an annual physical examination, an older woman's fasting blood
sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional
finding obtained during a follow-up visit 2 weeks later is most indicative that
the client has diabetes mellitus (DM)?
a. An increased thirst with frequent urination
b. Blood glucose range during past two weeks was 110 to 125 mg/dl or 6.1 to
, HESI 799 RN Exit Exam (101-200) LATEST UPDATE 2024/2025 HESI EXIT
COMPREHENSIVE REVIEW B (Q& As) COMPLETE RATIONALE GRADED A+
7.0 mmol/L(SI)
c. Two-hour postprandial glucose tolerance test (GTT) is 160 mg/dL or 8.9
mmol/L (SI)
d. Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).: Repeat-
ed fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
7. A new mother tells the nurse that she is unsure if she will be able to
transition into parenthood. What action should the nurse take?
a. Provide reassurance to the client that these feeling are normal after delivery
b. Discuss delaying the client's discharge from the hospital for another 24 hrs.
c. Determine if she can ask for support from family, friend, or the baby's father.
d. Explain the differences between postpartum blues and postpartum depres-
sion.: Determine if she can ask for support from family, friend, or the baby's father
Rationale: Emotional support of significant family and friends can help a new mother
cope with anxiety about transitioning to parenthood. The nurse should ask the client
who is available to support her.
8. A client who was admitted yesterday with severe dehydration is complain-
ing of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour.
Which intervention should the nurse implement first?
a. Establish the second IV site
b. Asses the IV for blood return
c. Stop the normal saline infusion.
d. Discontinue the 24-gauge IV: Stop the normal saline infusion.
Rationale: If the IV has infiltrated or become dislodges, the fluid is infusing into
surrounding tissue and not into the vein. Stopping the infusion C is the priority action.
Establishing another IV site is necessary for fluid resuscitation after the infiltrated
infusion is discontinuing the IV (D) is necessary due to the pain, and a large gauge
needle is preferable.
9. An elderly female is admitted because of a change in her level of sensorium.
During the evening shift, the client attempts to get out bed and falls, breaking
her left hip. Buck's skin traction is applied to the left leg while waiting for
surgery. Which intervention is most important for the nurse to include in this
client's plan care?
a. Evaluate her response to narcotic analgesia
b. Asses the skin under the traction moleskin
, HESI 799 RN Exit Exam (101-200) LATEST UPDATE 2024/2025 HESI EXIT
COMPREHENSIVE REVIEW B (Q& As) COMPLETE RATIONALE GRADED A+
c. Place a pillow under the involved lower left leg
d. Ensure proper alignment of the leg in traction.: Ensure proper alignment of
the leg in traction.
Rationale: A fractured hip results in external rotation and shortening of the affected
extremity. With the application of Buck's skin traction proper alignment ensures the
transaction
S pull is exerted to align the fracture hip with the distal leg, immobilize the fractured
bone, and minimize muscle spasms and surrounding tissue injury related to the
fracture. A should be implement but improper pull of traction can increase pain and
soft tissue damage. B and C should be implemented but the greatest risk is improper
alignment of the traction.
10. An Unna boot is applied to a client with a venous stasis ulcer. One week
later, when the Unna boot is removed during a follow-up appointment, the
nurse observes that the ulcer site contains bright red tissue. What action
should the nurse take in response to this finding?
a. Immediately apply a pressure dressing
b. Document the ongoing wound healing.
c. Irrigate the wound with sterile saline
d. Obtain a capillary INR, measurement: Document the ongoing wound healing
Rationale: Appearance of granulation tissue is the best indicator of increased venous
retuns and ongoing wound healing
11. At the end of a preoperative teaching session on pain management tech-
niques, a client starts to cry and states, "I just know I can't handle all the pain."
What is the priority nursing diagnosis for this client?
a. Knowledge deficit
b. Anxiety
c. Anticipatory grieving
d. Pain (acute): anxiety
Rationale: The client is demonstrating only anxiety. There is no indication that the
client is presenting signs of A, C or D
12. The nurse note a visible prolapse of the umbilical cord after a client experi-
ences spontaneous rupture of the membranes during labor. What intervention
should the nurse implement immediately?
