HESI EXIT EXAM REVIEW (A NEW UPDATED
VERSION 2024-2025 WITH ACTUAL TEST
QUESTIONS AND CORRECT VERIFIED
ANSWERS WITH RATIONALE |GRADED A+
FULL REVISED EXAM (NIGHTINGALE
COLLEGE)
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of
dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the
nurse? - CORRECT ANSWER>>Review with the client the need to avoid foods that are rich in milk and
cream
A male client with hypertension, who received new antihypertensive prescriptions at his last visit
returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits
that he has not been taking the prescribed medication because the drugs make him feel bad. In
explaining the need for hypertension control, the nurse should stress that an elevated BP places the
client at risk for which pathophysiological condition? - CORRECT ANSWER>>Stroke secondary to
hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has
a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What
action should the nurse implement? - CORRECT ANSWER>>Instruct the UAP to obtain soft blankets to
secure to the side rails instead of pillows.
An adolescent with major depressive disorder the past 12 days. Which assessment finding requires
immediate follow-up? has been taking duloxetine (Cymbalta) for - CORRECT ANSWER>>Describes life
without purpose
A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal
mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are
negative. What information should the nurse include in the client's teaching plan? - CORRECT
ANSWER>>Further evaluation involving surgery may be needed
A client who recently underwear a tracheostomy is being prepared for discharge to home. Which
instructions is most important for the nurse to include in the discharge plan? - CORRECT
ANSWER>>Teach tracheal suctioning techniques
,In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag
does not deflate completely during inspiration and the client's respiratory rate is 14 breaths minute.
What action should the nurse implement? - CORRECT ANSWER>>Document the assessment data
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm
should the nurse investigate firs? - CORRECT ANSWER>>Respiratory apnea of 30 seconds
During a home visit, the nurse observed an elderly client with diabetes slip action should the nurse take
first? - CORRECT ANSWER>>Check the client for lacerations or fractures
At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the
nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which
action should the nurse take first? - CORRECT ANSWER>>Inform the anesthesia care provider
A 66-year-old woman is retiring and will no longer have a health insurance through her place of
employment. Which agency should the client be referred to by the employee health nurse for health
insurance needs? - CORRECT ANSWER>>Medicare
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To
determine if an $3 heart sound is present, what action should the nurse take first? - CORRECT
ANSWER>>Listen with the bell at the same location
A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset What snack
should the nurse instruct the client to take with the tetracycline? - CORRECT ANSWER>>Toasted wheat
bread and jelly
Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse
that the client is experiencing a complication? - CORRECT ANSWER>>"I have a headache that gets worse
when I sit up"
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in
keeping with the child's dietary restrictions. Which foods are contraindicated for this child? - CORRECT
ANSWER>>.Obtain a clean catch mid-stream specimen
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in
keeping with the child's dietary restrictions. Which foods are contraindicated for this child? - CORRECT
ANSWER>>Foods sweetened with aspartame
Before preparing a client for the first surgical case of the day, a part-time scrub nurse the circulating
nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should
the circulating nurse provide? - CORRECT ANSWER>>Direct the nurse to continue the surgical hand
scrub for a 5 minute duration
,Which breakfast selection indicates that the client understands the nurse's instructions about the
dietary management of osteoporosis? - CORRECT ANSWER>>Bagel with jelly and skim milk
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal
number of registered nurses will be working that shift. In planning assignments, which client should
receive the most care hours by a registered nurse (RN)? - CORRECT ANSWER>>.An 82-year-old client
with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied
and pierced the bottom of the child's foot. Which action should the nurse implement pediatrician's
office. Upon inspection, the nurse notes that the nail went through the shoe A mother brings her 6-year-
old child, who has just stepped on a rusty nail, to the first? - CORRECT ANSWER>>Cleanse the foot with
soap and water and apply an antibiotic ointment
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot , I have been applying
triple antibiotic ointment for two days, but there has been no improvement. What instruction should
the nurse provide? - CORRECT ANSWER>>Stop using the ointment and encourage complete drying of
the feet and wearing clean socks.
A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and
levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the
prescribed dosage is too high for this client? The client experiences - CORRECT ANSWER>>Palpitations
and shortness of breath
A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and
palpitations. Which finding is most important for the nurse to assess to the client? - CORRECT
ANSWER>>Obtain a list of medications taken for cardiac histony
The healthcare provider prescribes an IV solution of isoproterenol (Isupre) 1 mg in 250 ml of DsW at 300
mcghour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric
value only.) - CORRECT ANSWER>>75
The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that
apply - CORRECT ANSWER>>Fluid shifts from intravascular to interstitial area due to decreased serum
protein Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen Increased
circulating aldosterone levels that increase sodium and water retention
The nurse is auscultating a client's heart sounds. Which description should the nurse use to document
this sound? (Please listen to the audio first to select the option that applies) - CORRECT
ANSWER>>Murmur
, The healthcare provider prescribes celtazidime (Eortax) 35 mg every 8 hours IM for an concentration of
100 mg/ml. How many ml should the nurse administered for each dose? infant. The 500 mg vial is
labeled with the instruction to add 5.3 ml diluent to provide a (Enter numeric value only. If rounding is
required, round to the nearest tenth) - CORRECT ANSWER>>0.4
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days.
What assessment is most important for the nurse to complete? - CORRECT ANSWER>>Auscultate the
client 's bowel sounds
A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of
shortness of breath. The client tells the nurse that she wants "no heroic measures" taken if she stops
breathing, and she asks the nurse to document this in her medical record. What action should the nurse
implement? - CORRECT ANSWER>>Ask the client to discuss "do not resuscitate" with her healthcare
provider
client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed
diarrhea. The client has a new prescription to change the feeding to half strength. What intervention
should the nurse implement? - CORRECT ANSWER>>Add equal amounts of water and feeding to a
feeding bag and infuse at 50ml/hour
A female client reports that her hair is becoming coarse and breaking off, that the outer part of her
eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the
nurse to ask? - CORRECT ANSWER>>Have you noticed any changes in your fingernails?
A female client reports that her hair is becoming coarse and breaking off, that the outer part of her
eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the
nurse to ask? - CORRECT ANSWER>>Have you noticed any changes in your fingernails?
After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and
malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up
blood. What assessment finding warrants immediate intervention by the nurse? - CORRECT
ANSWER>>Capillary refill of 8 seconds
After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form
as a witness. What are the legal implications of the nurse's signature on the client's surgical consent
form? (Select all that apply) - CORRECT ANSWER>>The client voluntarily grants permission for the
procedure to be done The client is competent to sign the consent without impairment of judgment The
client understands the risks and benefits associated with the procedure
Following surgery, a male client with antisocial personality disorder frequently requests that a specific
nurse be assigned to his care and is belligerent when another nurse i assigned. What action should the
VERSION 2024-2025 WITH ACTUAL TEST
QUESTIONS AND CORRECT VERIFIED
ANSWERS WITH RATIONALE |GRADED A+
FULL REVISED EXAM (NIGHTINGALE
COLLEGE)
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of
dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the
nurse? - CORRECT ANSWER>>Review with the client the need to avoid foods that are rich in milk and
cream
A male client with hypertension, who received new antihypertensive prescriptions at his last visit
returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits
that he has not been taking the prescribed medication because the drugs make him feel bad. In
explaining the need for hypertension control, the nurse should stress that an elevated BP places the
client at risk for which pathophysiological condition? - CORRECT ANSWER>>Stroke secondary to
hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has
a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What
action should the nurse implement? - CORRECT ANSWER>>Instruct the UAP to obtain soft blankets to
secure to the side rails instead of pillows.
An adolescent with major depressive disorder the past 12 days. Which assessment finding requires
immediate follow-up? has been taking duloxetine (Cymbalta) for - CORRECT ANSWER>>Describes life
without purpose
A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal
mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are
negative. What information should the nurse include in the client's teaching plan? - CORRECT
ANSWER>>Further evaluation involving surgery may be needed
A client who recently underwear a tracheostomy is being prepared for discharge to home. Which
instructions is most important for the nurse to include in the discharge plan? - CORRECT
ANSWER>>Teach tracheal suctioning techniques
,In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag
does not deflate completely during inspiration and the client's respiratory rate is 14 breaths minute.
What action should the nurse implement? - CORRECT ANSWER>>Document the assessment data
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm
should the nurse investigate firs? - CORRECT ANSWER>>Respiratory apnea of 30 seconds
During a home visit, the nurse observed an elderly client with diabetes slip action should the nurse take
first? - CORRECT ANSWER>>Check the client for lacerations or fractures
At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the
nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which
action should the nurse take first? - CORRECT ANSWER>>Inform the anesthesia care provider
A 66-year-old woman is retiring and will no longer have a health insurance through her place of
employment. Which agency should the client be referred to by the employee health nurse for health
insurance needs? - CORRECT ANSWER>>Medicare
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To
determine if an $3 heart sound is present, what action should the nurse take first? - CORRECT
ANSWER>>Listen with the bell at the same location
A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset What snack
should the nurse instruct the client to take with the tetracycline? - CORRECT ANSWER>>Toasted wheat
bread and jelly
Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse
that the client is experiencing a complication? - CORRECT ANSWER>>"I have a headache that gets worse
when I sit up"
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in
keeping with the child's dietary restrictions. Which foods are contraindicated for this child? - CORRECT
ANSWER>>.Obtain a clean catch mid-stream specimen
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in
keeping with the child's dietary restrictions. Which foods are contraindicated for this child? - CORRECT
ANSWER>>Foods sweetened with aspartame
Before preparing a client for the first surgical case of the day, a part-time scrub nurse the circulating
nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should
the circulating nurse provide? - CORRECT ANSWER>>Direct the nurse to continue the surgical hand
scrub for a 5 minute duration
,Which breakfast selection indicates that the client understands the nurse's instructions about the
dietary management of osteoporosis? - CORRECT ANSWER>>Bagel with jelly and skim milk
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal
number of registered nurses will be working that shift. In planning assignments, which client should
receive the most care hours by a registered nurse (RN)? - CORRECT ANSWER>>.An 82-year-old client
with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied
and pierced the bottom of the child's foot. Which action should the nurse implement pediatrician's
office. Upon inspection, the nurse notes that the nail went through the shoe A mother brings her 6-year-
old child, who has just stepped on a rusty nail, to the first? - CORRECT ANSWER>>Cleanse the foot with
soap and water and apply an antibiotic ointment
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot , I have been applying
triple antibiotic ointment for two days, but there has been no improvement. What instruction should
the nurse provide? - CORRECT ANSWER>>Stop using the ointment and encourage complete drying of
the feet and wearing clean socks.
A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and
levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the
prescribed dosage is too high for this client? The client experiences - CORRECT ANSWER>>Palpitations
and shortness of breath
A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and
palpitations. Which finding is most important for the nurse to assess to the client? - CORRECT
ANSWER>>Obtain a list of medications taken for cardiac histony
The healthcare provider prescribes an IV solution of isoproterenol (Isupre) 1 mg in 250 ml of DsW at 300
mcghour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric
value only.) - CORRECT ANSWER>>75
The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that
apply - CORRECT ANSWER>>Fluid shifts from intravascular to interstitial area due to decreased serum
protein Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen Increased
circulating aldosterone levels that increase sodium and water retention
The nurse is auscultating a client's heart sounds. Which description should the nurse use to document
this sound? (Please listen to the audio first to select the option that applies) - CORRECT
ANSWER>>Murmur
, The healthcare provider prescribes celtazidime (Eortax) 35 mg every 8 hours IM for an concentration of
100 mg/ml. How many ml should the nurse administered for each dose? infant. The 500 mg vial is
labeled with the instruction to add 5.3 ml diluent to provide a (Enter numeric value only. If rounding is
required, round to the nearest tenth) - CORRECT ANSWER>>0.4
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days.
What assessment is most important for the nurse to complete? - CORRECT ANSWER>>Auscultate the
client 's bowel sounds
A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of
shortness of breath. The client tells the nurse that she wants "no heroic measures" taken if she stops
breathing, and she asks the nurse to document this in her medical record. What action should the nurse
implement? - CORRECT ANSWER>>Ask the client to discuss "do not resuscitate" with her healthcare
provider
client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed
diarrhea. The client has a new prescription to change the feeding to half strength. What intervention
should the nurse implement? - CORRECT ANSWER>>Add equal amounts of water and feeding to a
feeding bag and infuse at 50ml/hour
A female client reports that her hair is becoming coarse and breaking off, that the outer part of her
eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the
nurse to ask? - CORRECT ANSWER>>Have you noticed any changes in your fingernails?
A female client reports that her hair is becoming coarse and breaking off, that the outer part of her
eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the
nurse to ask? - CORRECT ANSWER>>Have you noticed any changes in your fingernails?
After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and
malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up
blood. What assessment finding warrants immediate intervention by the nurse? - CORRECT
ANSWER>>Capillary refill of 8 seconds
After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form
as a witness. What are the legal implications of the nurse's signature on the client's surgical consent
form? (Select all that apply) - CORRECT ANSWER>>The client voluntarily grants permission for the
procedure to be done The client is competent to sign the consent without impairment of judgment The
client understands the risks and benefits associated with the procedure
Following surgery, a male client with antisocial personality disorder frequently requests that a specific
nurse be assigned to his care and is belligerent when another nurse i assigned. What action should the
