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Exam (elaborations)

HESI EXIT TEST Questions and Answers (100% Pass)

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The nurse identifies bright red drainage, about 2.4 inches (6 cm) in diameter, on the dressing of a client who is one day post abdominal surgery. Which action should the nurse take next? A. Mark the drainage on the dressing and take vital signs. B. Notify the healthcare provider of a potentia...

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  • October 22, 2024
  • 67
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • HESI EXIT
  • HESI EXIT
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1|Page | © copyright 2024/2025 | Grade A+




HESI EXIT TEST Questions and
Answers (100% Pass)
The nurse identifies bright red drainage, about 2.4 inches (6 cm) in diameter,

on the dressing of a client who is one day post abdominal surgery. Which

action should the nurse take next?




A. Mark the drainage on the dressing and take vital signs.


B. Notify the healthcare provider of a potential for hemorrhage.


C. Remove the dressing and assess the surgical incision site.


D. Reassess dressing in one hour for increased drainage.




Master01 | October, 2024/2025 | Latest update

, 1|Page | © copyright 2024/2025 | Grade A+

✓ A. Mark the drainage on the dressing and take vital signs.



✓ Rationale

✓ Drainage on a surgical dressing should be described by type, amount,

color, consistency, and odor, and the surgeon should be notified of

any excessive or abnormal drainage and significant changes in vital

signs. To determine that the drainage on an abdominal surgical

dressing is usual and not an indication of hemorrhage, marking the

drainage on the dressing assists in determining an increase in the

amount which is supported by any changes in vital signs that indicates

possible internal bleeding.




To assess a client's pupillary response to accommodation, a nurse should

perform which activity?




A. Cover one eye for one minute and note the pupil reaction when the cover

is removed.


B. Shine a light into the client's eye and watch the pupil response in the

opposite eye.


C. Touch the cornea with a piece of sterile cotton and observe for a change

in pupil size.



Master01 | October, 2024/2025 | Latest update

, 1|Page | © copyright 2024/2025 | Grade A+

D. Ask the client to look at a distant object and then at an object held 6-8

inches (10 cm) from the nose.


✓ D. Ask the client to look at a distant object and then at an object held

6-8 inches (10 cm) from the nose.



✓ Rationale

✓ To check the accommodation response, the client should gaze and

fixate on an object 2 to 3 feet away, then bring the object closer until

the client is fixated on the object at 6 to 8 inches (10 cm) and identify

pupillary constriction as the client focuses on the near object.




The nurse is inspecting the client's eyes. Which finding can be normal based

on skin color?




A. Inward-turned eyelashes.


B. Horizontal palpebrale fissure.


C. Slightly yellow sclerae.


D. Light blue appearance.




Master01 | October, 2024/2025 | Latest update

, 1|Page | © copyright 2024/2025 | Grade A+

✓ C. Slightly yellow sclerae



✓ Rationale

✓ Recognizing normal variations in individuals with varying skin tones

helps the nurse differentiate any early signs of pathology, such as

yellow sclerae. Recognizing age-related changes will also assist the

nurse to differentiate pathological changes in the elderly.




The nurse identifies a client with mental impairment and decreased nutritional

intake. They have increased confusion and have had a weight loss of over 30

pounds in the last 6 months. Based on the nursing problem of decreased

nutritional intake, which short-term goal best is for this client?




A. Eat 50% of six small meals each day by the end of one week.


B. Meals prepared during hospitalization will be fed by the nurse.


C. Verbalize understanding of plan and of intention to eat meals.


D. Demonstrate progressive weight gain toward the ideal weight.




Master01 | October, 2024/2025 | Latest update

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