HESI EXIT ACTUALEXAM 2024-2025 COMPLETE
QUESTIONS AND DETAILED VERIFIED ANSWERS AND
RATIONALE /A+ GRADE
A morbidly obese client is scheduled for gastric bypass surgery. The client
completes the required preoperative nutritional counseling and signs the operative
permit. To promote effective discharge planning, which intervention is most
important for the nurse to implement?
• Discuss small, low fat, low sugar meal preparation techniques.
A client who was splashed with a chemical has both eyes covered with
bandages. When assisting the client with eating, which intervention should the
nurse instructthe UAP to implement?
• Orient the client to the location of the food on the plate.
A client is admitted for an exacerbation of heart failure (HF) and is being treated
with diuretics for fluid volume excess. In planning nursing care, which
interventions should the nurse include? (Select all that apply.)
• • Observe for evidence of hypokalemia
• Teach the client how to restrict dietary sodium
• Weight the client daily, in the morning
While changing the dressing of a client who is immobile, the nurse observes a
redand swollen wound with a moderate amount of yellow and green drainage
and a foul odor. Given there is a positive methicillin-resistant Staphylococcus
aureus (MRSA), which is the most important action for the nurse to take?
• Administer prescribed antibiotics.
A client who has asthma receives a new prescription for a corticosteroid inhaler.
The client expresses concern about taking steroid medications. What information
should the nurse provide the client about the use of this maintenance inhaler?
• Systemic side effects are reduced when taken by inhalation
,The healthcare provider prescribes a sedative for a client with severe
hypothyroidism. The nurse plans to contact the provider to review the safety of
theprescription for the client and consults first with the charge nurse. The charge
nurse notes that the prescription is written legally and completely. How should
thecharge nurse respond?
• Assume responsibility for discussing the concern with the provider.
In assessing a client twelve hours following transurethral resection of the
prostate(TURP), the nurse observes that the urinary drainage tubing contains a
large amount of clear pale pink urine and the continuous bladder irrigation is
infusing slowly. Which action should the nurse implement?
• Ensure that no dependent loops are present in the tubing.
Which information should the nurse include in the discharge teaching plan of a
client with low back pain who is taking cyclobenzaprine to control muscle
spasms?
• Use cold and allergy medications only as directed by a healthcare provider.
A client with deep vein thrombosis (DVT) is receiving a continuous
intravenous heparin infusion. The client now has tarry, black diarrhea and
reports abdominal pain. Which actions should the nurse implement? (Select all
that apply)
• • Monitor stools for presence of blood
• Auscultate bowel sounds in all quadrants
• Review last partial thromboplastin time results.
Which laboratory results should the nurse closely monitor in a client who has
end-stage renal disease (ESRD)?
• • Serum potassium, calcium, and phosphorus.
A mal client who was in a motor vehicle collision yesterday is receiving a unit of
packed red blood cells. When half of the unit is infused, the client reports lower
, back pain, and the nurse observes a fine rash over his chest and back. Which
intervention should the nurse implement?
• Replace the transfusion with normal saline
When developing a teaching plan for a client with newly diagnosed Type 1
diabetes, the nurse should explain that an increased thirst is an early sign of
diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to
implement if this sign of DKA occurs?
• Give a dose of regular insulin as prescribed
Which information is most important to include in the teaching plan for a client
who is discharged after a thyroidectomy for Grave's disease?
• Daily hormone replacement will be needed for the rest of the client's life.
The nurse is planning discharge instructions for a client with type 2 diabetes
who will be starting exenatide. Which information should be included in the
discharge instructions?
• Notify your healthcare provider if you start having abdominal pain.
Which breakfast selection should he nurse recommend for a 16-year-old
withdiarrhea?
• Oatmeal, banana, and herbal tea.
The nurse is preparing to administer 1.6 mL of medication intramuscularly to a
4-month-old infant. Which action should the nurse include?
• Divide the medication into two injections with volumes under 1 mL.
A school-aged child with chronic renal failure receives a prescription from the
healthcare provider for losartan. Which action should the nurse implement prior to
administering the medication?
• Evaluate the ability to swallow medication.
QUESTIONS AND DETAILED VERIFIED ANSWERS AND
RATIONALE /A+ GRADE
A morbidly obese client is scheduled for gastric bypass surgery. The client
completes the required preoperative nutritional counseling and signs the operative
permit. To promote effective discharge planning, which intervention is most
important for the nurse to implement?
• Discuss small, low fat, low sugar meal preparation techniques.
A client who was splashed with a chemical has both eyes covered with
bandages. When assisting the client with eating, which intervention should the
nurse instructthe UAP to implement?
• Orient the client to the location of the food on the plate.
A client is admitted for an exacerbation of heart failure (HF) and is being treated
with diuretics for fluid volume excess. In planning nursing care, which
interventions should the nurse include? (Select all that apply.)
• • Observe for evidence of hypokalemia
• Teach the client how to restrict dietary sodium
• Weight the client daily, in the morning
While changing the dressing of a client who is immobile, the nurse observes a
redand swollen wound with a moderate amount of yellow and green drainage
and a foul odor. Given there is a positive methicillin-resistant Staphylococcus
aureus (MRSA), which is the most important action for the nurse to take?
• Administer prescribed antibiotics.
A client who has asthma receives a new prescription for a corticosteroid inhaler.
The client expresses concern about taking steroid medications. What information
should the nurse provide the client about the use of this maintenance inhaler?
• Systemic side effects are reduced when taken by inhalation
,The healthcare provider prescribes a sedative for a client with severe
hypothyroidism. The nurse plans to contact the provider to review the safety of
theprescription for the client and consults first with the charge nurse. The charge
nurse notes that the prescription is written legally and completely. How should
thecharge nurse respond?
• Assume responsibility for discussing the concern with the provider.
In assessing a client twelve hours following transurethral resection of the
prostate(TURP), the nurse observes that the urinary drainage tubing contains a
large amount of clear pale pink urine and the continuous bladder irrigation is
infusing slowly. Which action should the nurse implement?
• Ensure that no dependent loops are present in the tubing.
Which information should the nurse include in the discharge teaching plan of a
client with low back pain who is taking cyclobenzaprine to control muscle
spasms?
• Use cold and allergy medications only as directed by a healthcare provider.
A client with deep vein thrombosis (DVT) is receiving a continuous
intravenous heparin infusion. The client now has tarry, black diarrhea and
reports abdominal pain. Which actions should the nurse implement? (Select all
that apply)
• • Monitor stools for presence of blood
• Auscultate bowel sounds in all quadrants
• Review last partial thromboplastin time results.
Which laboratory results should the nurse closely monitor in a client who has
end-stage renal disease (ESRD)?
• • Serum potassium, calcium, and phosphorus.
A mal client who was in a motor vehicle collision yesterday is receiving a unit of
packed red blood cells. When half of the unit is infused, the client reports lower
, back pain, and the nurse observes a fine rash over his chest and back. Which
intervention should the nurse implement?
• Replace the transfusion with normal saline
When developing a teaching plan for a client with newly diagnosed Type 1
diabetes, the nurse should explain that an increased thirst is an early sign of
diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to
implement if this sign of DKA occurs?
• Give a dose of regular insulin as prescribed
Which information is most important to include in the teaching plan for a client
who is discharged after a thyroidectomy for Grave's disease?
• Daily hormone replacement will be needed for the rest of the client's life.
The nurse is planning discharge instructions for a client with type 2 diabetes
who will be starting exenatide. Which information should be included in the
discharge instructions?
• Notify your healthcare provider if you start having abdominal pain.
Which breakfast selection should he nurse recommend for a 16-year-old
withdiarrhea?
• Oatmeal, banana, and herbal tea.
The nurse is preparing to administer 1.6 mL of medication intramuscularly to a
4-month-old infant. Which action should the nurse include?
• Divide the medication into two injections with volumes under 1 mL.
A school-aged child with chronic renal failure receives a prescription from the
healthcare provider for losartan. Which action should the nurse implement prior to
administering the medication?
• Evaluate the ability to swallow medication.
