HESI 799 RN Exit Exam Questions and
Answers Graded A+
A male client is admitted for the removal of an internal fixation that was inserted
for the fracture ankle. During the admission history, he tells the nurse he recently
received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus
aureus (MRSA) wound infection. Which action should the nurse take? (Select all
that apply.)
a. Collect multiple site screening culture for MRSA
b. Call healthcare provider for a prescription for linezolid (Zyrovix)
c. Place the client on contact transmission precautions
d. Obtain sputum specimen for culture and sensitivity
e. Continue to monitor for client sign of infection. - Correct answer-a. Collect
multiple site screening culture for MRSA
c. Place the client on contact transmission precautions
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,e. Continue to monitor for client sign of infection.
Rationale: Until multi-site screening cultures come back negative (A), the client
should be maintained on contact isolation(C) to minimize the risk for nosocomial
infection. Linezolid (Zyvox), a broad spectrum anti-infecting, is not indicated,
unless the client has an active skin structure infection cause by MRSA or
multidrug- resistant strains (MDRSP) of Staphylococcus aureus. A sputum culture
is not indicated D) based on the client's history is a wound infection.
A vacuum-assistive closure (VAC) device is being use to provide wound care for a
client who has stage III pressure ulcer on a below-the- knee (BKA) residual limb.
Which intervention should the nurse implement to ensure maximum effectiveness
of the device?
a. Empty the device every 8 hours and change the dressing daily ensure sterility
b. Extended the transparent film dressing only to edge of wound to prevent tension.
c. Ensure the transparent dressing has no tears that might create vacuum leaks
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,d. Use an adhesive remover when changing the dressing to promote comfort. -
Correct answer-Ensure the transparent dressing has no tears that might create
vacuum leak
Rationale: The nurse should ensure that the VAC transparent film is intact, without
tears or loose edges C) because a break in the seal resulting in drying the wound
and decreasing the vacuum. The vacuum-assisted closure (VAC) device uses an
open sponge in the wound bed, sealed with a transparent film dressing and tube
extrudes to a suction device that exert negative pressure to remove excess wound
fluid, reduce the bacterial count and stimulate granulation. The VAC is changed
every other day or third day, not (A) depending on the stage of wound healing and
emptied when full or weekly. The transparent wound dressing should extend 3 to 5
cm beyond the wound edges, not (B) to ensure and airtight seal. Adhesive
removers leave a reduce that binder transparent film adherence (D)
The nurse is developing the plan of care for a client with pneumonia and includes
the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary
secretions." Which intervention is most important for the nurse to include in the
client's plan of care?
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, a. Increase fluid intake to 3,000 ml/daily
b. Administer O2 at 5L/mint per nasal cannula
c. Maintain the client in a semi Fowler's position
d. Provide frequent rest period. - Correct answer-Increase fluid intake to 3,000
ml/daily
Rationale: The plan of care should include an increase in fluid intake (A) to liquefy
and thin secretions for easier removal of thick pulmonary secretion which
facilitates airway clearance. (B) should be implemented for signs of hypoxia (C)
implemented to facilitate lung expansion, and (D) implemented for activity
intolerance, but these interventions do not have the priority of (A)
The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test.
Which instruction should the nurse provide to the adult male client?
a. Clearance around the meatus, discard first portion of voiding, and collect the rest
in a sterile bottle
b. Urinate at specific time, discard the urine, and collect all subsequent urine
during the next 24 hours.
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Answers Graded A+
A male client is admitted for the removal of an internal fixation that was inserted
for the fracture ankle. During the admission history, he tells the nurse he recently
received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus
aureus (MRSA) wound infection. Which action should the nurse take? (Select all
that apply.)
a. Collect multiple site screening culture for MRSA
b. Call healthcare provider for a prescription for linezolid (Zyrovix)
c. Place the client on contact transmission precautions
d. Obtain sputum specimen for culture and sensitivity
e. Continue to monitor for client sign of infection. - Correct answer-a. Collect
multiple site screening culture for MRSA
c. Place the client on contact transmission precautions
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,e. Continue to monitor for client sign of infection.
Rationale: Until multi-site screening cultures come back negative (A), the client
should be maintained on contact isolation(C) to minimize the risk for nosocomial
infection. Linezolid (Zyvox), a broad spectrum anti-infecting, is not indicated,
unless the client has an active skin structure infection cause by MRSA or
multidrug- resistant strains (MDRSP) of Staphylococcus aureus. A sputum culture
is not indicated D) based on the client's history is a wound infection.
A vacuum-assistive closure (VAC) device is being use to provide wound care for a
client who has stage III pressure ulcer on a below-the- knee (BKA) residual limb.
Which intervention should the nurse implement to ensure maximum effectiveness
of the device?
a. Empty the device every 8 hours and change the dressing daily ensure sterility
b. Extended the transparent film dressing only to edge of wound to prevent tension.
c. Ensure the transparent dressing has no tears that might create vacuum leaks
©COPYRIGHT 2025, ALL RIGHTS RESERVED 2
,d. Use an adhesive remover when changing the dressing to promote comfort. -
Correct answer-Ensure the transparent dressing has no tears that might create
vacuum leak
Rationale: The nurse should ensure that the VAC transparent film is intact, without
tears or loose edges C) because a break in the seal resulting in drying the wound
and decreasing the vacuum. The vacuum-assisted closure (VAC) device uses an
open sponge in the wound bed, sealed with a transparent film dressing and tube
extrudes to a suction device that exert negative pressure to remove excess wound
fluid, reduce the bacterial count and stimulate granulation. The VAC is changed
every other day or third day, not (A) depending on the stage of wound healing and
emptied when full or weekly. The transparent wound dressing should extend 3 to 5
cm beyond the wound edges, not (B) to ensure and airtight seal. Adhesive
removers leave a reduce that binder transparent film adherence (D)
The nurse is developing the plan of care for a client with pneumonia and includes
the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary
secretions." Which intervention is most important for the nurse to include in the
client's plan of care?
©COPYRIGHT 2025, ALL RIGHTS RESERVED 3
, a. Increase fluid intake to 3,000 ml/daily
b. Administer O2 at 5L/mint per nasal cannula
c. Maintain the client in a semi Fowler's position
d. Provide frequent rest period. - Correct answer-Increase fluid intake to 3,000
ml/daily
Rationale: The plan of care should include an increase in fluid intake (A) to liquefy
and thin secretions for easier removal of thick pulmonary secretion which
facilitates airway clearance. (B) should be implemented for signs of hypoxia (C)
implemented to facilitate lung expansion, and (D) implemented for activity
intolerance, but these interventions do not have the priority of (A)
The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test.
Which instruction should the nurse provide to the adult male client?
a. Clearance around the meatus, discard first portion of voiding, and collect the rest
in a sterile bottle
b. Urinate at specific time, discard the urine, and collect all subsequent urine
during the next 24 hours.
©COPYRIGHT 2025, ALL RIGHTS RESERVED 4
