Download H.E.S.I Comprehensive Exit Exam 2025 – 175+ Realistic Questions, In-Depth Rationales and more Exams Nursing in PDF only on Docsity!
HESI Comprehensive Exit Exam 2025 – 175+
Realistic Questions, In-Depth Rationales,
Adaptive Study Guide, and NCLEX-Focused
Review for Maximum Nursing Readiness
Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply. Keeping the room slightly darkened Placing the client in a room with a quiet roommate Encouraging isometric exercises if bed rest is prescribed Monitoring the client for changes in alertness or mental status Restricting visits to close family members and significant others and keeping visits short
- correct ans- - Keeping the room slightly darkened Monitoring the client for changes in alertness or mental status Restricting visits to close family members and significant others and keeping visits short Rationale: The room is kept slightly darkened, and bright lighting is avoided. The client is placed in a quiet private room without a telephone. The client is monitored for changes in alertness or mental status. Visitors are restricted to close family members and significant others, and visits are kept short. Any contact with visitors who upset or excite the client is avoided. A cerebral aneurysm is a thin-walled outpouching or dilation of an artery of the brain. When an aneurysm ruptures, bleeding into the subarachnoid space usually ensues. Aneurysm precautions are implemented to maintain a stable perfusion pressure and help prevent rupture. Stool softeners are administered to help keep the client from straining during defecation. Isometric exercises and use of the Valsalva maneuver are avoided because both increase intrathoracic and intraabdominal pressure. Bed rest with the head of the bed elevated 30 degrees may be prescribed. Some primary health care providers permit bathroom privileges for selected clients. If the client is allowed out of bed, the nurse stresses the importance of not bending over.
A nurse, providing information to a client who has just been diagnosed with diabetes mellitus, gives the client a list of signs/symptoms of hypoglycemia. Which answers by the client, on being asked to list the signs/symptoms, tells the nurse that the client understands the information? Select all that apply. Hunger Weakness Blurred vision Increased thirst Increased urine output - - correct ans- - Hunger Weakness Blurred vision Rationale: Signs/symptoms of hypoglycemia include weakness, double vision, blurred vision, hunger, tachycardia, and palpitations. The manifestations of diabetes mellitus (hyperglycemia) include polydipsia, polyuria, and polyphagia. A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse knows that what elements are related to the basic crutch stance? Select all that apply. Improves client's balance Hips and knees are extended Provides narrow base of support Axillae bear half of client's weight Incorrect Tripod position assumed before crutch walking Body alignment includes erect head and neck and straight vertebrae - - correct ans- - Improves client's balance Hips and knees are extended
than 60 mm Hg (7.95 kPa). On the basis of the ABG result, what does the nurse prepare to do? Continue monitoring the client Increase the amount of humidified oxygen Continue administering humidified oxygen Assist in intubating the client and beginning mechanical ventilation - - correct ans- - Assist in intubating the client and beginning mechanical ventilation Rationale: A client who sustains smoke inhalation is immediately treated with 100% humidified oxygen, delivered by way of face mask. An arterial oxygenation (Pao2) of less than 60 mm Hg (7.95 kPa) is an indication for intubation and mechanical ventilation. Normal arterial oxygenation is 80-100 mm Hg (10.6-13.33 kPa). Also, endotracheal intubation with mechanical ventilation is needed if the client exhibits respiratory stridor, crowing, or dyspnea, all of which indicate airway obstruction. A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper alignment is being maintained. Which action should the nurse take next? Providing pin care Medicating the client Notifying the primary health care provider Removing some weight from the traction - - correct ans- - Notifying the primary health care provider Rationale: The nurse realigns the client and, if this is ineffective in relieving the pain, should next notify the primary health care provider. A client in traction who complains of severe pain may require realignment or may have traction weights that are too heavy. Severe leg pain, once traction has been established, indicates a problem. Provision of pin care is not related to the problem as described. The client should be medicated after an attempt has been made to determine and treat the cause; the cause of the
severe pain should be investigated first. The nurse should never remove the weights from the traction without a specific prescription to do so. A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the appropriate action on the part of the nurse? Bivalve the cast Use a nail file to smooth the rough edges Ask the primary health care provider to reapply the cast Place small pieces of tape over the rough edges of the cast - - correct ans- - Place small pieces of tape over the rough edges of the cast Rationale: The appropriate action by the nurse is to petal (place small pieces of tape over) the rough edges of the cast to minimize the irritation. Bivalving is performed if the limb swells and the cast becomes too tight. Using a nail file to smooth the rough edges could cause pieces of the cast to fall into the cast, possibly resulting in the disruption of skin integrity. It is not necessary to contact the primary health care provider, and there is no reason to reapply the cast. A client says to the nurse, "My doctor just left. He told me that my abdominal scan showed a mass in my pancreas and that it's probably cancer. Does this mean I'm going to die?" How does the nurse interpret the client's initial reaction? Fear Denial Acceptance Anger - - correct ans- - Fear Rationale: The nurse interprets the client's initial reaction as fear. Fear is a response to a threat that is consciously recognized as a danger. In this situation, the client's reaction
Cough Fatigue and lethargy Dizziness and fatigue Numbness and tingling of the fingers or toes - - correct ans- - Numbness and tingling of the fingers or toes Rationale: Ergotamine is an antimigraine medication. Prolonged administration or an excessive dosage may produce ergotamine poisoning (ergotism). Signs/symptoms include nausea, vomiting, weakness in the legs, pain in the limb muscles, and numbness and tingling of the fingers and toes. The client is instructed to report these signs/symptoms to the primary health care provider if they occur. Cough, fatigue, lethargy, and dizziness are side effects and not adverse effects of the medication. A client diagnosed with post-traumatic stress disorder tells the nurse that he/she has stopped taking his/her prescribed medication because he/she didn't like how the medication was making him/her feel. Which initial response by the nurse is appropriate? "That's all right. I'd stop, too, if it made me feel funny." "Tell me more about how the medication was making you feel." "Did you let your doctor know that you stopped taking the medication?" "It doesn't make sense to stop the medication. I don't know why you took it upon yourself to do that." - - correct ans- - "Tell me more about how the medication was making you feel." Rationale: The appropriate response by the nurse acknowledges the client's feelings and opens the channel of communication between the nurse and client. "That's all right. I'd stop, too, if it made me feel funny," indicating approval, is a nontherapeutic response and is therefore inappropriate. "Did you let your doctor know that you stopped taking the medication?" may be an appropriate question at some point during the conversation, but it is not the most appropriate initial question. "It doesn't make sense to stop the medication. I don't know why you took it upon yourself to do that" demeans the client.
A nurse provides information to a client diagnosed with peripheral vascular disease about ways to limit the disease's progression. Which measures does the nurse tell the client to take? Select all that apply. Crossing the legs at the ankles only Engaging in exercise such as walking on a daily basis Washing the feet daily with a mild soap and drying them well Inspecting the feet at least once a week for injuries, especially abrasions Using a heating pad on the legs to help keep the blood vessels dilated - - correct ans- - Engaging in exercise such as walking on a daily basis Washing the feet daily with a mild soap and drying them well Rationale: Long-term management of peripheral vascular disease consists of measures that increase peripheral circulation. The client is instructed to exercise regularly and is encouraged to walk for 20 minutes each day. The client also needs to wash the feet daily with a mild soap, to dry the feet well, and to inspect the feet daily for injuries or abrasions. Crossing the legs at any level should be avoided because it promotes vasoconstriction. Keeping the extremities warm is important; however, heating pads and hot water bottles should not be placed on the extremity. Sensitivity may be diminished in the affected extremity, increasing the risk for burns. Also, direct application of heat increases the oxygen and nutritional requirements of the tissue even further. A client diagnosed with depression is anorexic. Which measure does the nurse take to assist the client in meeting nutritional needs? Providing food and fluid as the client requests Offering high-calorie and high-protein foods and fluids frequently throughout the day Completing the dietary menu for the client to ensure that adequate nutrition is provided Weighing the client daily so that the client may determine whether the nutritional plan is working - - correct ans- - Offering high-calorie and high-protein foods and fluids frequently throughout the day
"Why don't you really want to attend?" "This is what your primary health care provider has prescribed for you as part of the treatment plan." "OK, let's have you attend music therapy. You can sing there. How does that sound?" "Perhaps you could attend and talk to the other clients and see what they're drawing and painting." - - correct ans- - "Perhaps you could attend and talk to the other clients and see what they're drawing and painting." Rationale: The correct response encourages the client to socialize and deflects the client's attention from the issue of drawing and painting. "Why don't you really want to attend?" challenges the client. "This is what your primary health care provider has prescribed for you as part of the treatment plan" ignores the client's rights. "OK, let's have you attend music therapy. You can sing there. How does that sound?" does not address the client's concern. A hospitalized female client demonstrating mania enters the unit community room and says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse? "Why are you saying that?" "Stop saying that. It's not true!" "You wouldn't like someone saying that to you. Would you?" "Don't say that. If you can't control yourself, we'll help you." - - correct ans- - "Don't say that. If you can't control yourself, we'll help you." Rationale: The nurse should respond using a firm, calm approach, providing the client with clear expectations. The appropriate response is the only one that involves a firm, calm approach and offers the client help if she needs it. The other three statements challenge the client. A nurse working the evening shift is helping clients get ready for sleep. A female client diagnosed with mania is hyperactive and pacing the hallway. What is the most appropriate action the nurse can take?
Stay with the client and observe her behavior Take the client to the bathroom and provide her with a warm bath Tell the client that it is time for sleep and that she needs to go to her room Tell the client that other clients are trying to sleep and that she is being disruptive - - correct ans- - Take the client to the bathroom and provide her with a warm bath Rationale: At bedtime, the nurse should take the client to the bathroom and provide warm baths, soothing music, and medication when indicated. For the client with mania, the nurse needs to promote relaxation, rest, and sleep and to minimize manic behavior. The nurse should encourage frequent rest periods during the day and keep the client in areas of low stimulation. The client should not consume products containing caffeine. Staying with the client and observing her behavior, telling the client that it is time to go to sleep and to go to her room, and telling the client that other clients are trying to sleep and that she is being disruptive do not address the client's needs and are not measures that will help the client relax and sleep. Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information "I need to limit my intake of fluids while I'm taking this medication." "I need to stop the medication and call my doctor if I have severe diarrhea." "I can expect skin redness and a rash when I take this medication." "I may get a burning feeling in my throat, but it's normal and will go away." - - correct ans-
- "I need to stop the medication and call my doctor if I have severe diarrhea." Rationale: The client understands the information if stating, "I need to stop the medication and call my doctor if I have severe diarrhea." The client is instructed to report a rash, sore throat, fever, unusual bruising or bleeding, weakness, tiredness, or numbness. A burning sensation in the throat or skin, severe diarrhea, and abdominal pain are signs of overdose. Colchicine is classified as an antigout agent. It interferes with the capacity of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client should maintain a high fluid intake (eight to ten 8-oz [235 mL] glasses of fluid per day) while taking the medication.
Obsessive-compulsive disorder Dependent personality disorder - - correct ans- - Obsessive-compulsive disorder Rationale: Obsessive-compulsive disorder is an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear, or worry; by repetitive behaviors aimed at reducing anxiety; or by a combination of such thoughts (obsessions) and behaviors (compulsions). The client is inflexible and rigid, and is highly critical of self and others. The characteristics of dependent personality disorder include neediness and self-sacrificing and submissive behaviors. The client with avoidant personality disorder is extremely shy, feels inadequate, and is sensitive to rejection. Agoraphobia is the fear of open spaces. A nurse is developing a plan of care for a client admitted to the nursing unit with a diagnosis of paranoid personality disorder. On which characteristic of the disorder does the nurse base the plan of care? Inflexible and rigid Self-sacrificing and submissive Highly critical of self and others Projecting blame, possibly becoming hostile - - correct ans- - Projecting blame, possibly becoming hostile Rationale: A client with paranoid personality disorder projects blame, is suspicious of others, and may become hostile or violent. The client also experiences cognitive or perceptual distortions. A client who is inflexible and rigid and is highly critical of self and others is showing signs/symptoms of obsessive-compulsive disorder. Being self- sacrificing and submissive is a characteristic of a client with dependent personality disorder. A client on the mental health unit says to the nurse, "Everything is contaminated." The client scrubs his/her hands if forced to touch any object. While planning care, what does the nurse remember about compulsive behavior?
Temporarily eases anxiety in the client Is an attempt on the client's part to punish self Is an attempt on the client's part to seek the attention of others Is a response by the client to voices saying that everything is contaminated and that he/she must engage in this behavior - - correct ans- - Temporarily eases anxiety in the client Rationale: Compulsions are ritualistic behaviors that an individual feels driven to perform in an attempt to reduce anxiety. Obsessions are thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind. The other options identify interpretations of the client's obsessive behavior. A male client arrives at the emergency department and reports to the nurse, "I woke up this morning and couldn't move my arms." He also tells the nurse that he works in a factory and witnessed an accident 3 weeks ago in which a fellow employee's hands were severed by a machine. What is the priority response by the nurse? Assessing the client for organic causes of loss of arm movement Calling the crisis intervention team and asking them to assess the client Performing active and passive range-of-motion (ROM) exercises of the client's arms Asking the client to move his arms and documenting the loss of movement he has experienced - - correct ans- - Assessing the client for organic causes of loss of arm movement Rationale: The priority is assessing the client for organic causes of loss of arm movement and ruling out any neurological disorders. After it has been determined that there is no physiological basis for the problem, further psychiatric evaluation can be done. Encouraging the client to move his arms and performing active and passive ROM exercises have no beneficial effect in this situation. In fact, either option could be harmful if there is a physiological basis for the client's problem. A nurse is assigned to conduct an admission assessment of a client with a diagnosis of bipolar disorder. What does the nurse plan to do first?
the onset or exacerbation of the sign/symptom. A person with severe anxiety may focus on a particular detail or many scattered details. The person may have difficulty noticing what is going on in the environment, even when it is pointed out by another. Learning and problem-solving are not possible at this level of anxiety, and the client may be dazed and confused. PTSD is characterized by repeated re-experiencing of a highly traumatic event that involved actual or threatened death or serious injury to self or others to which the individual responded with intense fear, helplessness, or horror. Obsessions are thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind. Compulsions are ritualistic behaviors that an individual feels driven to perform in an attempt to reduce anxiety. A client experiencing delusions says to the nurse, "I am the only one who can save the world from all of the terrorists." What is the appropriate response by the nurse? "Tell me your plan for saving the world." "Why do you think that you can accomplish this by yourself?" "I don't think anyone can save the world from the terrorists by himself/herself." "You must be powerful. Do you really believe that you can do this by yourself?" - - correct ans- - "I don't think anyone can save the world from the terrorists by himself/herself." Rationale: The appropriate response by the nurse is "I don't think anyone can save the world from the terrorists by himself/herself." The nurse should not go along with or reinforce the client's delusion. The nurse should respond to the client by presenting reality. "Tell me your plan for saving the world," "Why do you think that you can accomplish this by yourself?" and "You must be powerful. Do you really believe you can do this by yourself?" all reinforce the delusion and encourage further conversation about it. A client diagnosed with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply. Eat foods that are low in fat and protein
Obtain pneumococcal and influenza vaccines Drink copious amounts of fluid and void frequently Avoid contact with any individual who has signs/symptoms of a cold Avoid contact with all individuals other than immediate family members - - correct ans-
- Drink copious amounts of fluid and void frequently Avoid contact with any individual who has signs/symptoms of a cold Rationale: Hemorrhagic cystitis is an adverse effect of this medication. The client is encouraged to drink copious amounts of fluid at least 24 hours before, during, and after chemotherapy, and avoid contact with individuals who are ill, have a cold, or have recently received a live-virus vaccine. The client is also encouraged to void frequently to prevent cystitis. The client is not to receive immunizations without the primary health care provider's approval, because they could diminish the body's resistance, putting the client at increased risk for infection. It is not necessary for the client to avoid contact with all individuals other than immediate family members. The client should, however, avoid contact with individuals who are ill, have a cold, or have recently received a live- virus vaccine. Encouraging adequate dietary intake is appropriate, but a low-protein or low-fat diet is not necessary. The client who is scheduled to undergo chemotherapy asks the nurse, "Is my hair going to fall out?" What does the nurse tell the client? Her hair will definitely fall out She should not be worrying about her hair at this point Her hair may fall out but will regrow after the chemotherapy is discontinued Vigorous hair-brushing is important while the client is undergoing chemotherapy to prevent hair loss - - correct ans- - Her hair may fall out but will regrow after the chemotherapy is discontinued Rationale: Some chemotherapeutic agents cause hair loss, and the client should be informed of this possibility. The client should also be reassured that chemotherapy- related hair loss is temporary and that the hair will regrow after the chemotherapy is discontinued, perhaps in a different shade, color, or texture. Telling the client that her hair will definitely fall out is incorrect and telling her that she should not be worrying
emphasizes that any yellow discoloration of the skin will disappear in a few hours. Fluorescein angiography provides a detailed image and permanent record of eye circulation. Photographs are taken in rapid succession after the intravenous administration of dye. After the test, the client may feel weak and nauseated, and the urine will be bright green until the dye has been excreted. Once the nausea has resolved, the client is encouraged to drink fluids to eliminate the dye, and instructed to avoid direct sunlight until pupil dilation returns to normal. An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which characteristic of the disorder does the nurse expect the client to exhibit? Select all that apply. Nausea Eye pain Vomiting Headache Diminished central vision Increased light perception - - correct ans- - Nausea Eye pain Vomiting Headache Rationale: In acute closed-angle glaucoma, the onset of signs/symptoms is acute and the client complains of sudden excruciating pain around the eyes that radiates over the sensory distribution of the fifth cranial nerve. Headache or brow ache, nausea, vomiting, and abdominal discomfort may also occur. Other signs/symptoms of glaucoma include seeing colored halos around lights, sudden blurred vision with decreased light perception, and loss of peripheral vision. A nurse is caring for a client with open-angle glaucoma. The nurse knows that what agents are used to treat this condition?
Myotic agents Mydriatric agents Cycloplegic agents Anticholinergic agents - - correct ans- - Myotic agents Rationale: Miotic agents are used to treat glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye. Besides mydriatic agents, cycloplegic and anticholinergic agents are contraindicated in clients with glaucoma. An emergency department nurse assessing a client with Bell's palsy collects subjective and objective data. Which finding does the nurse expect to note? A symmetrical smile Tightening of all facial muscles Ability to wrinkle the forehead on request Complaints of inability to close the eye on the affected side - - correct ans- - Complaints of inability to close the eye on the affected side Rationale: The onset of Bell's palsy is acute. Maximal paralysis occurs within 5 days in almost all clients. Pain behind the ear or on the face may precede paralysis by a few hours or days. The disorder is characterized by a drawing sensation and paralysis, not tightening, of all facial muscles on the affected side. The client cannot close the eye, wrinkle the forehead, smile, whistle, or grimace. The face appears masklike and sags. Taste is usually impaired to some degree, but this symptom seldom persists beyond the second week of paralysis. Loss of peripheral vision is not associated with Bell's palsy. A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate? Asking the child to describe the intensity of the pain
