Latest HESI Exit Exam 2023-2024 Questions and Answers Already verified answers With Rationales Graded A+

Latest HESI Exit
Exam 2023-2024
Questions and
Answers Already
verified answers
With Rationales
Graded A+
A client with history of bilateral adrenalectomy is
admitted with a week, irregular pulse, and hypotension.
Which assessment finding warrants immediate
intervention by the nurse? - ANS-Ventricular
arrhythmias.
Rationale: adrenal crisis, a potential complication of
bilateral adrenalectomy, results in the loss of
mineralocorticoids and sodium excretions that is
characterized by hyponatremia, hyperkalemia,
dehydration, and hypotension. Ventricular arrhythmias
are life threatening and required immediate
intervention to correct critical potassium levels.
A client is receiving mesalamine 800 mg PO TID. Which
assessment is most important for the nurse to perform
to assess the effectiveness of the medication? - ANSBowel patterns
Rationale: the client should be assessed for a change in
bowel patterns to evaluate the effectiveness of
this medication because Mesalamine is used to treat
ulcerative colitis (a condition which causes swelling
and sores in the lining of the colon [large intestine] and
rectum) and also to maintain improvement of
ulcerative colitis symptoms. Mesalamine is in a class of
medications called anti-inflammatory agents. It
works by stopping the body from producing a certain
substance that may cause inflammation.
A client with cirrhosis of the liver is admitted with
complications related to end stage liver disease. Which
intervention should the nurse implement? (Select all that
apply.) - ANS-Monitor abdominal girth.
Increase oral fluid intake to 1500 ml daily.
Report serum albumin and globulin levels.
Provide diet low in phosphorous.
Note signs of swelling and edema.
Rational: monitoring for increasing abdominal girth and
generalized tissue edema and swelling are
focused assessments that provide data about the
progression of disease related complications. In
advanced cirrhosis, liver function failure results in low
serum albumin and serum protein levels, which
caused third spacing that results in generalized fluid
retention and ascites. Other options are not
indicated in end stage liver disease.
A female client with acute respiratory distress syndrome
(ARDS) is chemically paralyzed and sedated while she is
on as assist-control ventilator using 50% FIO2. Which
assessment finding warrants
immediate intervention by the nurse? - ANS-Diminished
left lower lobe sounds
Rationale: Diminished lobe sounds indicate collapsed
alveoli or tension pneumothorax, which required
immediate chest tube insertion to re-inflate the lung.
A client who sustained a head injury following an
automobile collision is admitted to the hospital. The
nurse include the client's risk for developing increased
intracranial pressure (ICP) in the plan of care. Which
signs indicate to the nurse that ICP has increased? - ANSIncreased Glasgow coma scale score.
Nuchal rigidity and papilledema.
Confusion and papilledema
Periorbital ecchymosis.
Rationale: papilledema is always an indicator of
increased ICP, and confusion is usually the first sign of
increased ICP. Other options do not necessarily reflect
increased ICP.
While assessing a radial artery catheter, the client
complains of numbness and pain distal to the insertion
site. What interventions should the nurse implement? -
ANS-Promptly remove the arterial catheter from the
radial artery.
A client is admitted with an epidural hematoma that
resulted from a skateboarding accident. To differentiate
the vascular source of the intracranial bleeding, which
finding should the nurse monitor? - ANS-Rapid onset of
decreased level of consciousness.
When preparing a client for discharge from the hospital
following a cystectomy and a urinary diversion to treat
bladder cancer, which instruction is most important for
the nurse to include in the client's discharge teaching
plan? - ANS-Report any signs of cloudy urine output.
After repositioning an immobile client, the nurse
observes an area of hyperemia. To assess for blanching,
what action should the nurse take? - ANS-Apply light
pressure over the area.
The nurse enters a client's room and observes the client's
wrist restraint secured as seen in the picture. What
action should the nurse take? - ANS-Reposition the
restraint tie onto the bedframe