HESI EXIT V1-V7 WITH RATIONALES
1. 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?
A. Remind the client that it is also important to switch to decaffeinated coffee and tea.
B. Suggest that the client also plan to eat frequent small meals to reduce discomfort
C. Review with the client the need to avoid foods that are rich in milk and cream.
D. Reinforce this teaching by asking the client to list a dairy food that he might select.
ANSWER: Review with the client the need to avoid foods that are rich in milk and cream.
Rationale:
Diets rich in milk and cream stimulate gastric acid secretion and should be avoided.
2. 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?
A. Blindness secondary to cataracts
B. Acute kidney injury due to glomerular damage
C. Stroke secondary to hemorrhage
D. Heart block due to myocardial damage
ANSWER: Stroke secondary to hemorrhage
Rationale:
Stroke related to cerebral hemorrhage is major risk for uncontrolled hypertension
3. 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?
A. Ensure that the UAP has placed the pillows effectively to protect the client.
B. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
C. Assume responsibility for placing the pillows while the UAP completes another task.
D. Ask the UAP to use some of the pillows to prop the client in a side lying position.
ANSWER: Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
Rationale:
The nurse should instruct the UAP to pad the side rails with soft blankest because the use of
pillows could result in suffocation and would need to be removed at the onset of the seizure. The
nurse can delegate paddling the side rails to the UAP
4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days.
Which assessment finding requires immediate follow-up?
A. Describes life without purpose
B. Complains of nausea and loss of appetite
C. States is often fatigued and drowsy
D. Exhibits an increase in sweating.
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,ANSWERS: Describes life without purpose
Rationale:
Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that is known to increase
the risk of suicidal thinking in adolescents and young adults with major depressive disorder. B, C
and D are side effects
5. 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?
A. Further evaluation involving surgery may be needed
B. A pelvic exam is also needed before cancer is ruled out
C. Pap smear evaluation should be continued every six month
D. One additional negative pap smear in six months is needed.
ANSWERS: Further evaluation involving surgery may be needed
Rationale:
An abdominal mass in a client with a family history for ovarian cancer should be evaluated carefully
6. 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?
A. Explain how to use communication tools.
B. Teach tracheal suctioning techniques
C. Encourage self-care and independence.
D. Demonstrate how to clean tracheostomy site.
ANSWERS: Teach tracheal suctioning techniques
Rationale:
Suctioning helps to clear secretions and maintain an open airway, which is critical.
7. 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?)
A. Encourage the client to take deep breaths
B. Remove the mask to deflate the bag
C. Increase the liter flow of oxygen
D. Document the assessment data
ANSWER: Document the assessment data
Rationale:
Reservoir bag should not deflate completely during inspiration and the client’s respiratory rate is
within normal limits.
8. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the
nurse take first?
A. Give the client 4 ounces of orange juice
B. Call 911 to summon emergency assistance
C. Check the client for lacerations or fractures
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, D. Asses clients blood sugar level
ANSWER: Check the client for lacerations or fractures
Rationale:
After the client falls, the nurse should immediately assess for the possibility of injuries and provide
first aid as needed
9. 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?
A. Ensure preoperative lab results are available
B. Start prescribed IV with lactated Ringer’s
C. Inform the anesthesia care provider
D. Contact the client’s obstetrician.
ANSWER: Inform the anesthesia care provider
Rationale:
Surgical preoperative instruction includes NPO after midnight the day of surgery to decrease the
risk of aspiration should vomiting occur during anesthesia. While it is possible the C-section will be
done on schedule or rescheduled for later in the day, the anesthesia provider should be notified
first.
10. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine
if an S3 heart sound is present, what action should the nurse take first?
A. Side the stethoscope across the sternum.
B. Move the stethoscope to the mitral site
C. Listen with the bell at the same location
D. Observe the cardiac telemetry monitor
ANSWER: Listen with the bell at the same location
Rationale:
The nurse uses the bell of the stethoscope to hear low-pitched sounds such as S3 and S4. The
nurse listens at the same site using the diaphragm the diaphragm and bell before moving
systematically to the next sites.
11. 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?
A. Woman, Infant, and Children program
B. Medicaid
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