HESI EXIT EXAMS VERSION 1 -7 COMPREHENSIVE
EXAMS GUARANTEED PASS RATE ALL GRADED
900+ GUIDED RATIONALES WITH EXPERT GUIDED
FEEDBACK LATEST UPDATE 2023/2024
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
d. Asses clients blood sugar level
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
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.
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.
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
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.
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
c. Medicare
d. Consolidated Omnibus Budget Reconciliation Act provision.
Medicare
Rationale: Title XVII of the social security Act of 1965 created Medicare Program to provide
medical insurance for person more than 65 years or older, disable or with permeant kidney
failure, WIC provides supplemental nutrition to meet the needs of pregnant of breastfeeding
woman, infants and children up to age of 6. Medicaid provides financial assistance to pay for
medical services for poor older adults, blind, disable and families with dependent children.
COBRA(D) health benefit provisions is a limited insurance plan for those who has been laid off
or become unemployed.
A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What
snack should the nurse instruct the client to take with the tetracycline?
a. Fruit-flavored yogurt.
b. Cheese and crackers.
c. Cold cereal with skim milk.
d. Toasted wheat bread and jelly
Toasted wheat bread and jelly
Rationale: Dairy products decrease the effect of tetracycline, so the nurse instructs the client to
eat a snack such as toast, which contains no dairy products and may decrease GI symptoms.
Following a lumbar puncture, a client voices several complaints. What complaint indicated to the
nurse that the client is experiencing a complication?
a. “I am having pain in my lower back when I move my legs”
b. “My throat hurts when I swallow”
c. “I feel sick to my stomach and am going to throw up”
d. I have a headache that gets worse when I sit up”
“I have a headache that gets worse when I sit up”
Rationale: A post-lumbar puncture headache, ranging from mild to severe, may occur as a result
of leakage of cerebrospinal fluid at the puncture site. This complication is usually managed by
bedrest, analgesic, and hydration.
An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with
incontinence. Which action should the nurse implement
a. Auscultate for renal bruits
b. Obtain a clean catch mid-stream specimen
c. Use a dipstick to measure for urinary ketone
d. Begin to strain the client’s urine.
Obtain a clean catch mid-stream specimen
Rationale: This elderly is experiencing symptoms of urinary tract infection. The nurse should
obtain a clean catch mid-stream specimen to determine the causative agent so an anti-infective
agent can be prescribed.
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are
in keeping with the child’s dietary restrictions. Which foods are contraindicated for this child?
a. Wheat products
b. Foods sweetened with aspartame.
c. High fat foods
d. High calories foods.
Foods sweetened with aspartame
Rationale: Aspartame should not be consumed by a child with PKU because ut is converted to
phenylalanine in the body. Additionally, milk and milk products are contraindicated for children
with PKU.
Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the
circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which
response should the circulating nurse provide?
a. Ask a more experience nurse to perform that scrub since it is the first time of the day
b. Validate the nurse is implementing the OR policy for surgical hand scrub
c. Inform the nurse that hand scrubs should be 3 minutes between cases.
d. Direct the nurse to continue the surgical hand scrub for a 5-minute duration.
Direct the nurse to continue the surgical hand scrub for a 5 minute duration
Rationale: The surgical hand scrub should last for 5 to 10 mints, so the nurse should be directed
to continue the vigorous scrub using a reliable agent for the total duration of 5 mints. It is not
necessary to reassign staff (A). The length of the hand scrub and subsequent scrubs during the
day require the same process for the same amount of time, (B and C)
Which breakfast selection indicates that the client understands the nurse’s instructions about the
dietary management of osteoporosis?
a. Egg whites, toast and coffee.
b. Bran muffin, mixed fruits, and orange juice.
c. Granola and grapefruit juice
d. Bagel with jelly and skim milk.
Bagel with jelly and skim milk
Rationale: D includes dairy products which contain calcium and does not include any foods that
inhibit calcium absorption. The primary dietary implication of osteoporosis is the need for
increased calcium and reduction in foods that decrease calcium absorption, such as caffeine and
excessive fiber.
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the
optimal number of registered nurses will be working that shift. In planning assignments, which
client should receive the most care hours by a registered nurse (RN)
a. A 34-year -old admitted today after an emergency appendendectomy who has a peripheral
intravenous catheter and a Foley catheter.
b. A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and
vomiting due to electrolyte disturbance following a race.
c. A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via
nasal cannula and has a saline-locked peripheral intravenous catheter.
d. An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a Foley
catheter and soft wrist restrains applied
An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a Foley catheter
and soft wrist restrains applied
Rationale: (D) describe the client at the most risk for injury and complications because of the
factor listed. (A) has complete the recovery period form anesthesia but requires critical care
because of the invasive lines and new abdominal incision. (B) is likely to be in excellent physical
condition and has one invasive line needed for rehydration. (C) is essentially stable, despite
having a chronic condition.
A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s
office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the
bottom of the child’s foot. Which action should the nurse implement first?