HESI E2 HESI Exit Exam - Set 3 - Part 1

Correct Answer: Moderate impairment in basic ADLs

The Katz Index scores one point for each independent activity. Four independent of six gives a score of four, reflecting moderate impairment. The nurse plans caregiver support for bathing and dressing now. Option a is incorrect because severe impairment corresponds to a Katz score of two or below. That score would mean the woman could complete only zero, one, or two basic activities of daily living unassisted. Option b is incorrect because total independence requires a perfect score of six, meaning every basic activity is performed without help. Needing assistance with bathing and dressing prevents reaching that ceiling on the Katz scale. Option d is incorrect because needing physical help with two activities is more than a minor limitation. The Katz Index treats any required assistance as dependence and places this client outside the no-help functional range described here.

Correct Answer: Gait belt with pivot to strong side

A gait belt with a pivot toward the strong side gives the nurse a secure grip while letting the client use the stronger leg to bear weight. This protects the nurse's back and preserves remaining mobility and dignity. Option b is incorrect because a mechanical lift is reserved for clients who cannot bear any weight or follow commands. Using one here would remove the client's chance to participate and could accelerate deconditioning during recovery. Option c is incorrect because lifting bodily places the entire load on the nurse's spine and raises the risk of staff injury. The technique also bypasses the client's own muscle effort, which slows progress toward independence. Option d is incorrect because an unassisted transfer ignores reported fatigue and partial weight-bearing status. Without supervision, a sudden loss of balance during the pivot could cause a fall and a new injury.

Correct Answer: Limited assistance with partial help

Limited assistance describes a caregiver who provides hands-on help with less than half of the task. This client completes face and mouth care alone but needs physical washing of back and legs, fitting this level. Option a is incorrect because setup alone means the caregiver arranges items and then leaves the client to finish every step. Here the aide must actively wash back and legs, going beyond simple preparation of supplies. Option b is incorrect because supervision means the caregiver only watches for safety without physical contact. The aide in this scenario actually performs part of the bathing, which moves the task into a higher assistance level. Option c is incorrect because total dependence means the caregiver performs every component of the task. The client washes face and brushes teeth alone, so significant self-care remains intact during the morning hygiene routine.

Correct Answer: Has selective IADL limitations

Instrumental activities include shopping, finances, transportation, food preparation, and medication management. This client handles some but loses finances and driving, so the deficits are selective rather than global. Targeted services such as a bill-paying program can fill gaps. Option a is incorrect because nursing home placement is considered when basic ADLs are lost or safety cannot be assured at home. Selective gaps can usually be filled by family help, transportation services, or community programs. Option c is incorrect because hospice is reserved for clients with a terminal prognosis of six months or less. Losing two instrumental activities does not indicate end-of-life status and would not, on its own, qualify the client. Option d is incorrect because intact function means independent performance of every complex daily task. Loss of finances and driving represents measurable decline, which the nurse should document and address with appropriate community resources and support

Correct Answer: Reposition the chair on the strong side

Placing the wheelchair on the strong right side lets the unaffected leg lead the pivot, improving balance and reducing fall risk. The nurse should also raise the footrests and use a gait belt before initiating the transfer. Option b is incorrect because lowering the bed alone does not solve the underlying hazard. Pivoting toward the weak side remains unsafe even at correct bed height, so chair placement must be corrected before further steps. Option c is incorrect because hospital socks without rubber treads actually increase slipping on smooth floors. Footwear with non-skid soles is preferred for any transfer, and footwear alone cannot offset the weak-side positioning hazard described. Option d is incorrect because charting an unsafe setup without correcting it leaves the client at fall risk. Documentation should follow the hands-on safety adjustment the nurse must perform first, never replace that corrective step.

Correct Answer: Review the chest x-ray for placement

Radiographic confirmation is the gold standard before first use of a newly inserted nasogastric tube. The x-ray verifies the distal tip sits within the stomach, ruling out airway or esophageal misplacement before any feeding or medication. Option a is incorrect because the air bolus technique produces a swooshing sound even when the tube ends in the lung or esophagus. Current standards reject this method as a sole verification due to false-positive rates. Option b is incorrect because dipping the external tip in water cannot determine where the internal end rests. The technique is no longer recommended and risks aspiration of water if the tube is sitting in the airway. Option d is incorrect because measuring external length helps track migration between feedings but does not confirm initial placement. A tube may sit at the marked length yet still be coiled in the esophagus or pleural space.

Correct Answer: Begin the prescribed tube feeding

Gastric aspirate is typically green-yellow or brown with a pH between one and five. A pH of three plus an unchanged external length supports correct gastric placement, so the nurse can safely proceed with the ordered tube feeding. Option a is incorrect because routine pre-feed x-rays are not warranted when bedside checks already match gastric criteria. Repeat radiographs at every feeding add cost and radiation exposure without improving safety beyond proper pH and length verification. Option b is incorrect because the findings indicate appropriate gastric placement rather than a tube that has advanced too far. Withdrawing the tube would interrupt prescribed nutrition and could displace it into the esophagus, raising aspiration risk. Option c is incorrect because repositioning is used for occluded drainage, not when aspirate values already confirm gastric placement. Adding an unnecessary recheck delays nutrition the provider has already ordered for this stable, alert client.

Correct Answer: Stop feeding and check gastric residual

Stopping the pump and measuring gastric residual identifies feeding intolerance before symptoms worsen. If residual is high, the nurse holds the feeding, elevates the head of bed, and notifies the provider for orders such as a prokinetic agent. Option a is incorrect because increasing the rate when the stomach is already distended worsens delayed emptying. Added volume raises pressure against the lower esophageal sphincter and can trigger reflux, vomiting, and silent aspiration. Option c is incorrect because giving an antiemetic first treats the symptom while ignoring the underlying cause. A pooled residual must be identified initially; otherwise an obstruction or intolerance can advance unnoticed during the masked nausea. Option d is incorrect because left-side positioning aids gastric emptying but does not address feeding intolerance directly. The pump should be stopped first; positioning then supports comfort once the gastric residual check has been completed.

Correct Answer: Give each medication separately, flush water

Each medication should be given alone with a small water flush between doses. Separate administration prevents drug-drug precipitation that can clog the tube and confirms that any obstruction or reaction can be linked to one specific medication. Option b is incorrect because crushing enteric-coated tablets destroys the protective layer designed to delay release until the small intestine. Without that coating, gastric acid degrades the drug or causes severe stomach irritation in the client. Option c is incorrect because combining several crushed tablets can produce a paste-like sludge inside the syringe and tubing. Interactions between active ingredients can form precipitates that lodge in the lumen and result in a blocked tube. Option d is incorrect because mixing medications into the formula reservoir leads to unpredictable dosing as the bag empties. Adherence of drug particles to bag and tubing also reduces the actual amount of medication the client receives.

Correct Answer: Low potassium, magnesium, and phosphorus

Refeeding syndrome produces intracellular shifts of potassium, magnesium, and phosphorus as insulin rises with renewed carbohydrate intake. These three electrolytes fall together and can trigger cardiac arrhythmias, respiratory failure, and neuromuscular weakness during the first week of feeding. Option a is incorrect because refeeding causes potassium to drop into cells along with phosphorus and magnesium. Elevations of these electrolytes would suggest renal failure or cell breakdown rather than the intracellular shifting pattern unique to refeeding. Option b is incorrect because sodium and calcium are not the hallmark imbalances of refeeding syndrome. Carbohydrate-driven insulin release primarily pulls potassium, magnesium, and phosphorus into cells, not the cations identified in this particular answer choice. Option c is incorrect because hyperglycemia can occur, but the danger of refeeding lies in falling intracellular electrolytes. Normal magnesium would actually argue against ref

Correct Answer: Increase irrigation rate per protocol

Bright red urine with clots after a prostate resection signals active bleeding and a need for faster flow. Increasing the irrigation rate dilutes the blood, flushes clots before they obstruct the catheter, and keeps urine at the goal pink color. Option a is incorrect because slowing the flow allows more time for clots to form and lodge within the catheter lumen. Bladder distention from obstruction would put traction on fresh surgical sutures and could provoke dangerous postoperative hemorrhage. Option b is incorrect because clamping a postoperative bladder catheter traps blood and clots against the surgical site. The resulting distention causes pain, raises bleeding pressure on the prostatic bed, and disrupts healing of cauterized tissue. Option d is incorrect because discontinuing irrigation removes the very intervention designed to prevent clot obstruction after this surgery. Continuous bladder irrigation continues until urine clears and is not stopped at the first sign of bleeding.

Correct Answer: Pull the pinna up and back

For a child age three years or older, the pinna is pulled up and back to straighten the ear canal. This adult-like maneuver opens the canal so the irrigation stream can reach impacted cerumen without striking the tympanic membrane directly. Option b is incorrect because pulling the pinna down and back is the technique used for children younger than three years. By age five the canal anatomy has matured, so the down-and-back maneuver no longer aligns the canal correctly. Option c is incorrect because the ear canal in a young child is naturally curved rather than straight. Holding the pinna in a neutral position blocks flow of the irrigation solution and pushes cerumen further toward the tympanic membrane. Option d is incorrect because some traction on the pinna is needed at every age to straighten the external auditory canal. Without traction, the bend in the canal traps fluid and reduces the effectiveness of cerumen removal.

Correct Answer: Inner canthus toward outer canthus

Directing the stream from inner canthus toward outer canthus moves contaminated fluid away from the nasolacrimal duct and the unaffected eye. Continuous irrigation should run for fifteen to twenty minutes when a chemical splash is involved. Option a is incorrect because flowing from outer to inner canthus pushes contaminated fluid toward the tear duct. From there the chemical can drain into the nose, sinuses, or the opposite eye, broadening rather than limiting the original exposure. Option b is incorrect because irrigating both eyes at once with the same stream guarantees cross contamination of any uninvolved eye. Each eye should be irrigated separately, with the affected side positioned lower than the unaffected side throughout. Option d is incorrect because aiming directly at the cornea or pupil can cause mechanical injury to delicate tissue. The stream should glance across the conjunctival sac at low pressure rather than striking the visual axis straight on.

Correct Answer: Thirty-five-mL syringe, nineteen-gauge angiocatheter

A thirty-five-milliliter syringe paired with a nineteen-gauge angiocatheter delivers about eight pounds per square inch of pressure. This range cleans loose debris from a chronic wound without injuring the fragile granulation tissue underneath the surface slough. Option a is incorrect because a bulb syringe produces low and inconsistent pressure that fails to remove slough. Although tap water can be acceptable in some home settings, the ordered solution here is normal saline and pressure remains inadequate. Option b is incorrect because cotton balls leave fibers in the wound bed and antiseptics can be cytotoxic to healing tissue. Normal saline irrigation at proper pressure is preferred over wiping or harsh chemical solutions for chronic wound cleansing. Option c is incorrect because wet-to-dry packing is a method of mechanical debridement rather than irrigation. The order asks for cleansing with saline, so packing strips alone do not deliver the pressurized rinse this wound requires.

Correct Answer: Cane goes in my left hand

The cane is held on the strong side, opposite the weak leg. With a left knee replacement, the cane belongs in the right hand. The right cane and left leg move forward together, followed by the right leg. Option a is incorrect because holding the cane in the right hand is the correct technique for this client. The right hand is opposite the affected left knee, so this statement reflects proper learning rather than a teaching deficit. Option c is incorrect because moving the cane forward together with the affected leg is the recommended gait pattern. This pairing distributes weight away from the surgical knee at the very moment that limb makes contact with the floor. Option d is incorrect because leading with the unaffected leg when climbing stairs is correct and reflects the up with the good rule. The strong leg pulls the body upward, then the cane and weak leg follow safely.

Correct Answer: Three-point non-weight-bearing crutch gait

The three-point gait is designed for clients with one non-weight-bearing leg and good arm strength. Both crutches and the affected leg advance together while the strong leg supports body weight, then the strong leg swings through to meet the crutches. Option a is incorrect because the four-point gait requires the client to bear weight on both legs in an alternating pattern. With a non-weight-bearing tibia fracture, placing any load on the right leg would disrupt healing. Option b is incorrect because the two-point gait still demands partial weight bearing on both legs as one crutch and the opposite foot advance together. This pattern is not safe for the strict non-weight-bearing restriction described. Option d is incorrect because the swing-through gait is typically used by clients with lower extremity paralysis who have strong arms. It is reserved for permanent weight-bearing limits, not a temporary fracture in an otherwise healthy young adult.

Correct Answer: Push walker forward, stay inside it

A rolling walker is pushed forward while staying close to the body so the client remains inside the support frame. Keeping the walker within reach maintains balance, reduces forward leaning, and allows the brakes to control unexpected motion. Option a is incorrect because a rolling walker has wheels designed to allow continuous forward motion without lifting. Lifting the device wastes energy and removes the wheels from the floor, which defeats the smooth glide the design provides. Option c is incorrect because pushing the walker an arm's length ahead forces the client to lean forward to reach it. That forward shift moves the center of gravity outside the support base and increases the risk of falls. Option d is incorrect because limiting use to short distances does not answer the technique question. A correctly used walker can be used safely throughout the day, and discouraging activity may worsen deconditioning and isolation at home.

Correct Answer: Strong leg, then crutches and affected leg

The rule for stairs is up with the good. The strong leg leads onto the higher step, then crutches and affected leg follow to the same step. This pattern keeps body weight on the stronger limb during upward push. Option a is incorrect because moving both legs together after the crutches eliminates the controlled stepping pattern used for crutch stair climbing. The combined motion increases the risk of losing balance and falling backward down the staircase. Option b is incorrect because leading with the affected leg places body weight on the injured ankle at the moment of upward thrust. The injured limb cannot reliably push the body upward and must follow rather than lead. Option d is incorrect because hopping on the affected leg puts full body weight on a fractured ankle. The impact would likely worsen the injury and remove the protection that proper crutch use is meant to provide.

Correct Answer: High risk; full prevention bundle

A Braden total score between ten and twelve places the client in the high-risk category. The nurse implements a prevention bundle that includes a pressure-redistribution surface, every-two-hour repositioning, heel offloading, moisture management, and nutrition optimization. Option a is incorrect because routine skin care is appropriate only for clients in the no-risk range of nineteen to twenty-three. A score of twelve falls well below that cutoff and demands targeted preventive interventions rather than ordinary care. Option b is incorrect because mild risk corresponds to scores between fifteen and eighteen, not twelve. Repositioning every four hours also falls short of the every-two-hour standard that applies at any documented pressure injury risk. Option c is incorrect because very high risk applies to scores of nine or below, which is one category lower in severity. Bedside rounds without specific preventive interventions also fail to describe an actual prevention bundle.

Correct Answer: Stage one pressure injury

Intact skin with non-blanchable erythema meets the definition of a stage one pressure injury. The skin is unbroken, but the area cannot blanch because superficial tissue damage has begun, calling for pressure relief and frequent reassessment. Option b is incorrect because a stage two injury features partial-thickness skin loss with exposed dermis, sometimes appearing as an open ulcer or ruptured blister. Intact skin here means the wound cannot be classified at stage two. Option c is incorrect because stage three involves full-thickness loss with visible subcutaneous fat, possibly with undermining or tunneling. Intact skin and mild tenderness alone do not indicate full-thickness damage and rule out this advanced stage. Option d is incorrect because unstageable injuries are full-thickness wounds where slough or eschar prevents visualization of the true depth. No slough or eschar is present here, and the skin surface remains intact rather than open.