HESI Exit Practice Questions and
Rationale (2) with reviewed answers
GRADED A+
The nurse has completed giving discharge instructions to a client who
has had a total joint replacement (TJR) of the knee with a metal
prosthetic system. The nurse determines that the client understands the
instructions if the client makes which statement?
1."Changes in the shape of the knee are
expected." 2."Fever, redness, and increased
pain are expected."
3."All caregivers should be told about the metal implant."
4."Bleeding gums or black stools may occur, but this is
normal."
- ANS- 3
A TJR is also known as a total joint arthroplasty (TJA). The client must
inform other caregivers of the presence of the metal implant because
certain tests and procedures will need to be avoided. After total knee
replacement, the client should report signs and symptoms of infection
and any changes in the shape of the knee. These could indicate
developing complications. With a metal implant, the client may be on
anticoagulant therapy and should report adverse effects of this therapy,
including bleeding from a variety of sources, and the client will need
antibiotic prophylaxis for invasive procedures.
The nurse is caring for a client after the application of a plaster cast for a
fractured left radius. The nurse should suspect impairment with the
neurovascular status of the client's casted extremity if which findings are
noted? Select all that apply.
,1.Capillary refill is less than 3 seconds 2.Pulses present and with
swollen, pink fingers
,3. Client report of severe, deep, unrelenting pain
4. Client report of pain as nurse assesses finger movement
5. Client report of numbness and tingling sensation in the fingers
- ANS- 3, 4, 5
The pressure in compartment syndrome, if unrelieved, will cause
permanent damage to nerve and muscle tissue distal to the pressure.
Circulatory damage may result in necrosis. Nerve and muscle damage
may result in permanent contractures, deformity of the extremity, and
functional impairment. Normal capillary refill time is 3 seconds or less.
Pink appearance and a pulse indicate adequate blood flow; swelling is
expected after a fracture. Client report of severe, deep, unrelenting pain;
client report of numbness and tingling sensation; and client report of
pain as the nurse assesses finger movement are indicative of
development of compartment syndrome.
A client with a 4-day-old lumbar vertebral fracture is experiencing
muscle spasms. Which are interventions to aid the client in relieving the
spasm? Select all that apply.
1.Ice
2.Heat
3.Analgesi
cs
4.Muscle relaxers
5.Intermittent
traction
- ANS- 2, 3, 4, 5
Heat, analgesics, muscle relaxers, and traction all may be used to relieve
the pain of muscle spasm in the client with a vertebral fracture. Ice is
applied to a painful site only for the first 48 to 72 hours (depending on
the health care provider's preference) after an injury. Application of ice
, to the spine of a client could be uncomfortable and could result in
feelings of being chilled.
The nurse is caring for a client who had surgery to repair a fractured left-
sided hip using a posterior approach. In implementing hip precautions,
which action should the nurse teach the client to avoid?
1.Crossing legs at the ankle
2. Using an elevated toilet seat 3.Placing a pillow between the legs
4.Keeping the legs abducted from the midline
- ANS- 1
Rationale (2) with reviewed answers
GRADED A+
The nurse has completed giving discharge instructions to a client who
has had a total joint replacement (TJR) of the knee with a metal
prosthetic system. The nurse determines that the client understands the
instructions if the client makes which statement?
1."Changes in the shape of the knee are
expected." 2."Fever, redness, and increased
pain are expected."
3."All caregivers should be told about the metal implant."
4."Bleeding gums or black stools may occur, but this is
normal."
- ANS- 3
A TJR is also known as a total joint arthroplasty (TJA). The client must
inform other caregivers of the presence of the metal implant because
certain tests and procedures will need to be avoided. After total knee
replacement, the client should report signs and symptoms of infection
and any changes in the shape of the knee. These could indicate
developing complications. With a metal implant, the client may be on
anticoagulant therapy and should report adverse effects of this therapy,
including bleeding from a variety of sources, and the client will need
antibiotic prophylaxis for invasive procedures.
The nurse is caring for a client after the application of a plaster cast for a
fractured left radius. The nurse should suspect impairment with the
neurovascular status of the client's casted extremity if which findings are
noted? Select all that apply.
,1.Capillary refill is less than 3 seconds 2.Pulses present and with
swollen, pink fingers
,3. Client report of severe, deep, unrelenting pain
4. Client report of pain as nurse assesses finger movement
5. Client report of numbness and tingling sensation in the fingers
- ANS- 3, 4, 5
The pressure in compartment syndrome, if unrelieved, will cause
permanent damage to nerve and muscle tissue distal to the pressure.
Circulatory damage may result in necrosis. Nerve and muscle damage
may result in permanent contractures, deformity of the extremity, and
functional impairment. Normal capillary refill time is 3 seconds or less.
Pink appearance and a pulse indicate adequate blood flow; swelling is
expected after a fracture. Client report of severe, deep, unrelenting pain;
client report of numbness and tingling sensation; and client report of
pain as the nurse assesses finger movement are indicative of
development of compartment syndrome.
A client with a 4-day-old lumbar vertebral fracture is experiencing
muscle spasms. Which are interventions to aid the client in relieving the
spasm? Select all that apply.
1.Ice
2.Heat
3.Analgesi
cs
4.Muscle relaxers
5.Intermittent
traction
- ANS- 2, 3, 4, 5
Heat, analgesics, muscle relaxers, and traction all may be used to relieve
the pain of muscle spasm in the client with a vertebral fracture. Ice is
applied to a painful site only for the first 48 to 72 hours (depending on
the health care provider's preference) after an injury. Application of ice
, to the spine of a client could be uncomfortable and could result in
feelings of being chilled.
The nurse is caring for a client who had surgery to repair a fractured left-
sided hip using a posterior approach. In implementing hip precautions,
which action should the nurse teach the client to avoid?
1.Crossing legs at the ankle
2. Using an elevated toilet seat 3.Placing a pillow between the legs
4.Keeping the legs abducted from the midline
- ANS- 1
