HESI EXIT EXAM- LATEST
COMPLETE QUESTIONS &
ANSWERS (CORRECT SOLUTIONS)
1. A nurse is evaluating care of an immobilized patient. Which action will
... [Show More] thenurse take?
a. Focus on whether the interdisciplinary team is satisfied with the care.
Compare the patient’s actual outcomes with the outcomes in the care
b. plan.
Involve primarily the patient’sfamily and health care team to
c. determine goal achievement.
Use objective data solely in determining whether interventions have
d. been successful.
ANS: B
From your perspective as the nurse, you are to evaluate outcomes and
response to nursing care and compare the patient’s actual outcomes with theoutcomes
selected during planning. Ask if the patient’s expectations (subjective data) of care are
being met, and use objective data to determine the success of interventions. Just as it
was important to include the patient during the assessment and planning phase of the
care plan, it is essential to have the patient’s evaluation of the plan of care, not just the
patient’s familyand health care team.
2. A nurse is supervising the logrolling of a patient. To which patient is thenurse most
likely providing care?
a. A patient with neck surgery
b. A patient with hypostatic pneumonia
c. A patient with a total knee replacement
d. A patient with a Stage IV pressure ulcer
ANS: A
A nurse supervises and aids personnel when there is a health care provider’s
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order to logroll a patient. Patients who have suffered from spinal cord injury orare
recovering from neck, back, or spinal surgery often need to keep the spinalcolumn in
straight alignment to prevent further injury. Hypostatic pneumonia, total knee replacement,
and Stage IV ulcers do not have to be logrolled.
3. The nurse is providing teaching to an immobilized patient with
impaired skin integrity about diet. Which diet will the nurse recommend?
a. High protein, high calorie
b. High carbohydrate, low fat
c. High vitamin A, high vitamin E
d. Fluid restricted, bland
ANS: A
Because the body needs protein to repair injured tissue and rebuild depleted protein
stores, give the immobilized patient a high-protein, high-calorie diet. A highcarbohydrate, low-fat diet is not beneficial for an immobilized patient.Vitamins B and C
are needed rather than A and E. Fluid restriction can be detrimental to the immobilized
patient; this can lead to dehydration. A bland diet is not necessary for immobilized
patients.
4. The nurse is caring for a patient who has had a stroke causing total paralysis
of the right side. To help maintain joint function and minimize
the disability from contractures, passive ROM will be initiated. Whenshould the
nurse begin this therapy?
a. After the acute phase of the disease has passed
b. As soon as the ability to move is lost
c. Once the patient enters the rehab unit
d. When the patient requests it
ANS: B
Passive ROM exercises should begin as soon as the patient’s ability to move the extremity
or joint is lost. The nurse should not wait for the acute phase to end. It may be some time
before the patient enters the rehab unit or the patientrequests it, and contractures could
form by then.
5. The nurse is admitting a patient who has been diagnosed as having had
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a stroke. The health care provider writes orders for “ROM as needed.”What
should the nurse do next?
a. Restrict patient’s mobility as much as possible.
b. Realize the patient is unable to move extremities.
c. Move all the patient’s extremities.
d. Further assess the patient.
ANS: D
Further assessment of the patient is needed to determine what the patient is able to
perform. Some patients are able to move some joints actively, whereasthe nurse passively
moves others. With a weak patient, the nurse may have tosupport an extremity while the
patient performs the movement. In general, exercises need to be as active as health and
mobility allow.
6. A nurse is assessing pressure points in a patient placed in the Sims’position.
Which areas will the nurse observe?
a. Chin, elbow, hips
b. Ileum, clavicle, knees
c. Shoulder, anterior iliac spine, ankles
d. Occipital region of the head, coccyx, heels
ANS: B
In the Sims’ position pressure points include the ileum, humerus, clavicle, knees, and
ankles. The lateral position pressure points include the ear, shoulder, anterior iliac
spine, and ankles. The prone position pressure pointsinclude the chin, elbows, female
breasts, hips, knees, and toes. Supine position pressure points include the occipital
region of the head, vertebrae, coccyx, elbows, and heels.
7. The patient is admitted to a skilled care unit for rehabilitation after thesurgical
procedure of fixation of a fractured left hip. The patient’s nursingdiagnosis is
Impaired physical mobility related to musculoskeletal impairment from surgery and
pain with movement. The patient is able to
use a walker but needs assistance ambulating and transferring from the bed [Show Less]