HESI Practice Exam Prep 2025: 100+ Practice Questions with Expert Answers and In-Depth Rationales for Nursing School Exams

A nurse notes documentation in the client’s medical record indicating that the client has a
stage II pressure ulcer. On the basis of this information, which finding does the nurse expect
to note? – – correct ans- -Rationale: A stage I ulcer is characterized by intact skin that is red
and does not blanch under external pressure. A stage II ulcer is characterized by nonintact
skin. There is partial-thickness skin loss, and the wound may appear as an abrasion, a
shallow crater, or a blister. A stage III ulcer is characterized by full-thickness skin loss, and the
subcutaneous tissue may be damaged or necrotic. The damage extends down to but not
through the underlying tissues. A deep crater-like appearance or eschar is present. A stage IV
ulcer is characterized by full-thickness skin loss with extensive destruction, tissue necrosis, or
damage to muscle, bone, or supporting structures. Sinus tracts may develop.
A nurse is providing instruction in how to perform Kegel exercises to a client with stress
incontinence. What does the nurse tell the client to do?
Always perform the exercises while lying down
Expect an improvement in the control of urine in about 1 week
Tighten the pelvic muscles for as long as 5 minutes, three or four times a day
Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10 – – correct
ans- -Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10
Rationale: Kegel exercises strengthen the muscles of the pelvic floor. To perform the
exercises, the client is taught to tighten the pelvic muscles to a slow count of 10, then relax
to a slow count of 10. The client is also instructed to do this exercise 15 times while lying
down, sitting up, and standing (a total of 45 repetitions). The client is told that an
improvement in the control of urine will be noticed after several weeks of the exercises;
some individuals report that improvement takes as long as 3 months.
A nurse is planning to teach a crutch gait to a client who will be using wooden axillary
crutches. The nurse knows that what elements are related to the basic crutch stance? Select
all that apply.
Improves client’s balance
Hips and knees are extended
Provides narrow base of support
Axillae bear half of client’s weight Incorrect
Tripod position assumed before crutch walking
Body alignment includes erect head and neck and straight vertebrae – – correct ans-
Improves client’s balance
Hips and knees are extended
Tripod position assumed before crutch walking
Body alignment includes erect head and neck and straight vertebrae
Rationale: The basic crutch stance is the tripod position, which the client assumes before
crutch walking. It is formed when the crutches are placed 15 cm (6 inches) in front of and 15
cm (6 inches) to the side of each foot. This position improves the client’s balance by
providing a wider, not narrower, base of support. The body alignment of the client in the
tripod position includes an erect head and neck, straight vertebrae, and extended hips and
knees. The axillae should not bear any weight.