HESI E2 HESI Exit Exam - Set 3 - Part 2

Correct Answer: Unstageable pressure injury

When slough or eschar covers the wound bed so the actual depth cannot be seen, the wound is documented as unstageable. After debridement and the base becomes visible, the wound is reassigned to its true stage. Option a is incorrect because a stage two pressure injury is shallow with a visible pink wound bed or a ruptured blister. The wound base is hidden under slough and eschar, which moves it out of stage two. Option b is incorrect because stage three requires direct visualization of subcutaneous fat without exposed bone, tendon, or muscle. With the base obscured, the nurse cannot confirm fat involvement and cannot assign a definite stage three classification. Option c is incorrect because stage four requires that bone, tendon, or muscle be visible at the wound base. The covered base prevents the nurse from verifying any of these structures, so a stage four classification cannot be applied accurately.

Correct Answer: Reposition every two hours, offload heels

Repositioning every two hours and offloading heels with pillows under the calves is the most evidence-based prevention strategy. These actions redistribute pressure away from bony prominences and protect the heels, where injuries are common and difficult to heal. Option b is incorrect because a doughnut cushion concentrates pressure around its rim, cutting off blood flow in a ring around the targeted area. Current practice avoids these cushions because they create new pressure injuries rather than preventing them. Option c is incorrect because massaging reddened areas damages already compromised capillary beds. Friction and shear forces from massage worsen tissue injury and are explicitly contraindicated in current evidence-based pressure injury prevention guidelines. Option d is incorrect because keeping the head of bed at ninety degrees increases shear forces as the client slides down the mattress. The recommended position is below thirty degrees whenever clinical condition allows sa

Correct Answer: Hydrocolloid kept on several days

A hydrocolloid dressing provides an occlusive moist environment, supports autolytic debridement, and can stay in place for several days. These properties suit a small stage two pressure injury with minimal drainage and reduce disturbance to fragile pink healing tissue. Option a is incorrect because dry gauze permits the wound bed to dry out and adheres to delicate granulation tissue. Removing dry gauze tears healing cells away from the surface, slowing repair and causing unnecessary discomfort during dressing changes. Option b is incorrect because calcium alginate is designed for moderate to heavy exudate. Packing alginate into a wound with minimal drainage would dry out the dressing and the surrounding skin, defeating the goal of a moist surface. Option d is incorrect because wet-to-dry dressings are intended for mechanical debridement of necrotic tissue and require frequent changes. They are no longer favored, and they cause pain and bleeding in a clean, granulating stage two wound.

Correct Answer: Administer scheduled multimodal analgesia

Multimodal analgesia combines a scheduled non-opioid such as acetaminophen with as-needed opioids and non-drug measures. This approach controls postoperative pain at a lower opioid dose, reduces side effects, and addresses the client's concern about opioid dependence. Option a is incorrect because distraction alone is unlikely to control pain rated at seven out of ten after major abdominal surgery. Non-drug techniques are valuable supplements but cannot replace pharmacologic therapy at this severe level. Option c is incorrect because waiting for severe escalation contradicts evidence that early treatment of moderate pain prevents windup of nociceptive pathways. Letting pain climb to ten increases total opioid required and worsens recovery experience. Option d is incorrect because direct heat over a fresh abdominal incision can damage tissue, increase swelling, and risk burns over numb skin. Heat is generally avoided over acute surgical sites within the first forty-eight hours afte

Correct Answer: Apply heat fifteen to twenty minutes

Heat therapy is applied for fifteen to twenty minutes per session with a barrier cloth between pad and skin. This duration delivers vasodilation and muscle relaxation while minimizing burn risk, especially for clients who use heat unsupervised at home. Option b is incorrect because sleeping on a heating pad allows continuous pressure and heat to one area for hours. This combination can produce serious burns, even with full sensation, because awareness of discomfort is suppressed during sleep. Option c is incorrect because the highest setting raises burn risk without speeding any therapeutic benefit. Moderate heat over a longer permitted interval is safer and more effective than brief exposure to a temperature that can scald skin. Option d is incorrect because placing the pad directly on bare skin removes the protective layer that diffuses heat. A thin towel or cloth between pad and skin reduces hot spots and helps prevent thermal injury during therapy.

Correct Answer: Fall asleep with television on nightly

Good sleep hygiene reserves the bed for sleep and intimacy only. Falling asleep with the television on disrupts the natural circadian rhythm through light and noise exposure and conditions the brain to associate bed with wakeful entertainment rather than rest. Option a is incorrect because a consistent bedtime is a foundation of sleep hygiene and reinforces the circadian rhythm. This statement reflects accurate teaching rather than a misunderstanding that the nurse would need to address before the client goes home. Option b is incorrect because cool, dark bedrooms support melatonin release and uninterrupted sleep cycles. This recommendation appears in every standard sleep hygiene plan, so the statement shows the client understood the teaching about the bedroom environment. Option c is incorrect because limiting caffeine after noon prevents stimulant effects from extending into evening hours. The client's awareness of caffeine timing demonstrates appropriate learning rather than a

Correct Answer: Same-sex Muslim caregivers perform washing

Islamic tradition specifies that same-sex Muslims wash the body, often family or community members. The body is wrapped in plain white cloth and prepared for burial within twenty-four hours. The nurse supports the family's role and protects privacy throughout. Option b is incorrect because Islamic tradition typically prohibits embalming. Adding chemical preservation before family viewing would conflict directly with religious requirements and would override the autonomy of the grieving relatives who already expressed cultural preferences. Option c is incorrect because a chaplain who is not a same-sex Muslim caregiver should not perform postmortem preparation under these traditions. The nurse coordinates with religious leaders the family identifies rather than imposing unfamiliar spiritual support unilaterally. Option d is incorrect because tubes and lines may need to remain in place if the death falls under medical examiner jurisdiction. Routine removal without checking the case s

Correct Answer: Clarify the order before administration

The letter u appears on the ISMP do-not-use list because handwritten u can be mistaken for a zero. Clarifying the order and requesting that the word units be spelled out removes the ambiguity that has caused fatal insulin overdoses. Option a is incorrect because assuming u means ten units accepts an unsafe abbreviation rather than correcting it. Any future reader of the chart could misinterpret the same notation, perpetuating the error and exposing the client to harm. Option b is incorrect because reading u as a zero would deliver one hundred units of regular insulin, a potentially fatal overdose. The very risk that prompted the ISMP guidance is reflected in this dangerous reading of the ambiguous abbreviation. Option d is incorrect because holding insulin allows persistent hyperglycemia in a client whose breakfast tray is on the way. The proper response is order clarification, not omission, since an appropriate insulin dose is clearly indicated by the morning glucose.

Correct Answer: At cart, preparation, and bedside

The three checks occur when removing the medication from storage, when preparing the dose, and at the bedside before administration. All three checks against the medication administration record catch wrong drug, wrong dose, or wrong client errors before harm. Option b is incorrect because reading u as a zero would deliver one hundred units of regular insulin, a potentially fatal overdose. The very risk that prompted the ISMP guidance is reflected in this dangerous reading of the abbreviation. Option c is incorrect because checking only at the cart cannot catch preparation errors such as drawing the wrong dose volume. Two later checks are designed to verify the dose at every stage between storage and the moment of administration. Option d is incorrect because one check during the entire pass leaves multiple medications unverified. The protocol mandates three separate checks per medication, not per shift, so each individual dose must be reviewed three times before administration.

Correct Answer: Right evaluation of response

The right evaluation of response is the post-administration check that the medication produced the intended therapeutic effect and did not cause harm. For an opioid drip this includes tracking pain score, sedation level, respiratory rate, and oxygen saturation. Option a is incorrect because the right indication confirms the medication is appropriate for the client's diagnosis at the time of the order. It is a pre-administration check rather than a follow-up assessment of how the client responded. Option b is incorrect because a single bedside check misses early errors that occur at retrieval or preparation. Catching a wrong vial at the cart prevents wasted time and stops a near-miss before the medication reaches the patient. Option c is incorrect because the right route ensures the medication is delivered by the prescribed pathway, such as intravenous versus oral. Verifying the route is part of preparation rather than the systematic post-dose assessment that this question describe

Correct Answer: Clarify the order, add leading zero

An order written as point five mg is on the ISMP do-not-use list because it can be misread as five mg, a tenfold overdose. The nurse calls the prescriber to clarify and documents the corrected order with a leading zero. Option a is incorrect because accepting an order without a leading zero perpetuates a writing style on the ISMP do-not-use list. Subsequent readers could overlook the decimal point and administer five milligrams of digoxin, a dangerous overdose. Option b is incorrect because rounding up to a higher dose without prescriber authorization changes the medication order. Digoxin has a narrow therapeutic index, so even a small increase could push the client into the toxic range with arrhythmias. Option d is incorrect because holding the medication without contacting the provider leaves a needed cardiac drug unadministered. The correct action is clarification of writing format, not assumption that the client refuses or that the drug should be skipped.

Correct Answer: Ventrogluteal on the lateral hip

Doses below one require a leading zero to highlight the decimal point. The nurse should clarify the order so it reads zero point five milligrams. Missing leading zeros have caused tenfold overdoses when a decimal point was overlooked. Option a is incorrect because the dorsogluteal site carries risk of sciatic nerve injury and inconsistent absorption due to overlying fat. Current best practice has moved away from this site in favor of ventrogluteal injection for adult patients. Option c is incorrect because the deltoid is limited to about two milliliters in adults and is best for vaccines and small-volume injections. A large-volume antibiotic order would exceed the safe deltoid limit and could damage local tissue. Option d is incorrect because the vastus lateralis is preferred mainly for infants younger than twelve months. In healthy adults it remains an acceptable site, but the ventrogluteal area is the first-choice recommendation for routine intramuscular injections.

Correct Answer: Stretch skin, inject, wait, withdraw

Z-track requires pulling the skin laterally about an inch, inserting the needle at ninety degrees, injecting slowly, waiting roughly ten seconds, then withdrawing the needle. The displaced layers form a zigzag track that seals medication inside the muscle. Option b is incorrect because injecting without skin traction allows irritating medication to leak back along a straight needle track. Massaging afterward worsens leakage and irritation of subcutaneous tissue, which is exactly the harm the Z-track method exists to prevent. Option c is incorrect because pinching the skin lifts the tissue and is used for subcutaneous injections, not intramuscular ones. The injection also should not be rushed since slow administration with a brief pause helps the medication disperse safely. Option d is incorrect because pulling the skin downward rather than laterally does not create the zigzag track that seals the medication path. Skipping the pre-withdrawal pause also raises the risk of leakage back al

Correct Answer: Stop infusion and remove catheter

Cool, pale, swollen skin around an intravenous site with reduced flow points to infiltration. The nurse stops the infusion, removes the catheter, elevates the extremity, and applies warm or cold compresses per facility policy before restarting in a different site. Option a is incorrect because slowing the rate allows fluid to continue leaking into the surrounding tissue. Each additional milliliter increases swelling and pressure, raising the risk of more serious soft tissue injury and possible nerve compression. Option b is incorrect because applying a warm compress before removing the catheter leaves the source of injury in place. Compresses are used after the catheter is out, as part of comfort and reabsorption care for the infiltrated tissue. Option c is incorrect because increasing the rate forces more fluid into tissue that already cannot accept it. The pressure increase compounds the infiltration and can lead to compartment syndrome in extreme cases without prompt removal.

Correct Answer: Waste remaining mg with a witness

Federal regulations require controlled substance waste to be witnessed by another licensed nurse and documented by both. Wasting at the point of preparation prevents diversion, supports accurate inventory counts, and protects both nurses from questions about missing medication. Option a is incorrect because slowing the rate allows fluid to continue leaking into the surrounding tissue. Each additional milliliter increases swelling and pressure, raising the risk of more serious tissue injury and possible nerve compression. Option b is incorrect because discarding controlled substances in regular trash violates federal record-keeping and disposal rules. The medication could be retrieved from the trash by unauthorized individuals and contributes to environmental contamination of the community water supply. Option d is incorrect because flushing controlled substances introduces them into wastewater systems and contaminates the water supply. Current guidance discourages flushing in favor of

Correct Answer: Hold dose, notify the provider

Bradycardia under sixty, new nausea, and yellow halos are classic signs of digoxin toxicity. The nurse holds the dose, notifies the provider, and anticipates orders for a digoxin level and serum potassium before any further dose is given. Option a is incorrect because saving leftover controlled medication creates an unsecured supply that can be lost, accessed by others, or used outside proper documentation. Each new dose should be drawn fresh from the dispensing system. Option c is incorrect because adjusting the dose without prescriber authorization changes the original medication order. Even a smaller dose can prolong toxicity, especially when the apical rate is already below the standard threshold for holding digoxin therapy. Option d is incorrect because waiting thirty minutes delays recognition of toxicity that the symptoms already strongly suggest. The nurse must act on present findings rather than waste time hoping that the apical rate spontaneously rises into safe range.

Correct Answer: Increase rate per protocol, reassess

Titration of high-alert vasopressors requires adjusting the rate in the direction needed to reach the ordered parameter. With a mean arterial pressure below goal, the nurse increases by the protocol increment and reassesses frequently until the target is achieved. Option a is incorrect because lowering the dose moves the client further from the ordered mean arterial pressure goal. Reducing vasopressor support during ongoing hypotension worsens organ perfusion and accelerates the progression of septic shock in this patient. Option b is incorrect because stopping a vasopressor without an order would cause an abrupt drop in pressure. Sudden discontinuation of high-alert infusions is reserved for clear evidence of harm such as severe arrhythmia, ischemia, or extravasation. Option c is incorrect because maintaining the current rate ignores a measured pressure that is below the ordered goal. Titration protocols expect the nurse to act within minutes rather than passively wait for spontaneous

Correct Answer: Hold and call for clarification

Combining a nonsteroidal anti-inflammatory with warfarin significantly raises bleeding risk by impairing platelet function and irritating the gastric mucosa. The nurse holds the dose, contacts the prescriber for clarification, and documents the rationale before any future administration. Option a is incorrect because monitoring an international normalized ratio does not eliminate the additive bleeding risk from this drug pairing. Gastrointestinal bleeding can occur even when the international normalized ratio remains within the usual therapeutic range expected on warfarin. Option b is incorrect because simply documenting and giving the drug ignores a known dangerous interaction. The nurse's responsibility includes recognizing high-risk combinations and stopping administration until the prescriber confirms that the benefit clearly outweighs the bleeding risk. Option d is incorrect because the nurse cannot substitute one medication for another without an order. Switching to acetamin

Correct Answer: Air NPH, air regular, clear first

The nurse injects air into the cloudy NPH vial, then air into the clear regular vial, then draws the regular insulin first followed by the NPH. The clear before cloudy sequence prevents contamination of regular insulin with the longer-acting NPH. Option b is incorrect because drawing NPH first contaminates the regular insulin vial when the syringe returns. NPH suspension would shorten or unpredictably extend the action profile of any regular insulin pulled later from the same vial during preparation. Option c is incorrect because separate syringes negate the entire purpose of the mixing technique and add an extra needle stick on the client. Regular and NPH are designed to be combined safely in one syringe. Option d is incorrect because shaking insulin vials denatures the protein and creates foaming that affects accuracy of dose measurement. The cloudy NPH is gently rolled between the palms, while regular insulin requires no agitation at all before drawing.

Correct Answer: Keep my vitamin K intake consistent

Consistent vitamin K intake stabilizes the international normalized ratio because warfarin works by interfering with vitamin K dependent clotting factors. The client should keep a steady amount of leafy greens rather than eliminating them, since wide swings destabilize anticoagulation control. Option a is incorrect because a typical multivitamin contains only a small, consistent amount of vitamin K. Stopping it abruptly may itself swing the international normalized ratio and is not necessary unless the prescriber specifically advises discontinuation. Option b is incorrect because ibuprofen and other nonsteroidal anti-inflammatory drugs significantly increase bleeding risk when combined with warfarin. Acetaminophen is generally preferred for occasional headaches in clients on warfarin therapy unless contraindicated by liver disease. Option c is incorrect because eliminating all leafy greens dramatically reduces vitamin K and can push the international normalized ratio above the safe ran