NEWEST NUR 210 HESI RN EXIT EXAM COMPLETE
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES A NEW UPDATED VERSION LATEST 2026-2027
(100% VERIFIED ANSWERS) GUARANTEED PASS A+
1.A client with heart failure is prescribed furosemide. Which assessment finding requires
immediate intervention?
- A. Weight loss of 1 kg in 24 hours
- B. Serum potassium level of 3.2 mEq/L
- C. Blood pressure of 110/70 mm Hg
- D. Urine output of 50 mL/hour
Rationale:B. Serum potassium level of 3.2 mEq/L.Furosemide is a loop diuretic that causes
potassium wasting. Hypokalemia (normal 3.5–5.0 mEq/L) increases the risk of digoxin toxicity
and cardiac arrhythmias. Weight loss of 1 kg is expected fluid loss. BP 110/70 is acceptable.
Urine output 50 mL/hr is adequate.
2. A postoperative client reports sudden chest pain and shortness of breath. The nurse notes
oxygen saturation of 88%. Which action should the nurse take first?
- A. Administer morphine sulfate
- B. Apply supplemental oxygen
- C. Obtain a STAT chest X-ray
- D. Elevate the head of the bed
Rationale:B. Apply supplemental oxygen.The priority is treating hypoxemia. Oxygen should be
applied immediately to maximize oxygen delivery. Elevating HOB helps but does not address
low SpO2 as urgently. Morphine and X-ray come after stabilization.
3. A client with cirrhosis has ascites and is receiving spironolactone. Which laboratory finding
indicates a therapeutic effect?
- A. Decreased serum sodium
,- B. Increased urine output
- C. Decreased serum ammonia
- D. Increased serum albumin
Rationale:B. Increased urine output.Spironolactone is a potassium-sparing diuretic used to
manage ascites by increasing urine output and reducing fluid retention. It does not directly
affect ammonia or albumin. Sodium may decrease if fluid shifts, but that is not the primary
therapeutic indicator.
4.A client on mechanical ventilation has a sudden decrease in oxygen saturation and absent
breath sounds on the right side. What should the nurse suspect?
- A. Pulmonary embolism
- B. Right-sided pneumothorax
- C. Mucus plug in the left mainstem bronchus
- D. Displaced endotracheal tube into the right mainstem bronchus
Rationale:B. Right-sided pneumothorax.Absent breath sounds unilaterally with desaturation
after sudden change suggests pneumothorax, especially if the client is on PEEP. Right mainstem
intubation would cause absent left breath sounds. Mucus plug would be gradual.
5.A client with type 1 diabetes mellitus is found unresponsive. Which intervention should be
implemented first?
- A. Check blood glucose level
- B. Administer glucagon IM
- C. Start IV dextrose 50%
- D. Assess airway and breathing
Rationale:D. Assess airway and breathing.ABCs always come first. After securing the airway,
then blood glucose and treatment for hypoglycemia (glucagon or IV dextrose) can be given.
6. A nurse is caring for a client receiving a blood transfusion. Fifteen minutes after initiation,
the client reports low back pain and chills. What is the priority action?
,- A. Slow the infusion rate
- B. Stop the transfusion
- C. Notify the healthcare provider
- D. Administer acetaminophen
Rationale:B. Stop the transfusion.These symptoms indicate a possible acute hemolytic reaction.
The transfusion must be stopped immediately to prevent further reaction. The IV line is kept
open with normal saline.
7. A client with major depressive disorder is started on phenelzine, an MAOI. Which food
should the nurse instruct the client to avoid?
- A. Apples
- B. Aged cheese
- C. White bread
- D. Broccoli
Rationale:B. Aged cheese.MAOIs can cause hypertensive crises when combined with
tyramine-rich foods (aged cheese, cured meats, fermented products). Apples, bread, and
broccoli are low in tyramine.
8. A client with chronic kidney disease has a potassium level of 6.1 mEq/L. Which
electrocardiogram change would the nurse expect?
- A. Flattened T waves
- B. Prominent U waves
- C. Peaked T waves
- D. Prolonged PR interval
Rationale:C. Peaked T waves.Hyperkalemia (>5.5 mEq/L) causes tall, peaked T waves,
widened QRS, and eventually sine wave pattern. Flattened T waves and U waves occur in
hypokalemia.
, 9.A postpartum client with a third-degree perineal laceration reports not having had a bowel
movement for 3 days. Which medication should the nurse anticipate?
- A. Bisacodyl suppository
- B. Docusate sodium
- C. Magnesium citrate
- D. Mineral oil enema
Rationale:B. Docusate sodium.Stool softener is preferred postpartum, especially with
lacerations, to prevent straining. Stimulants (bisacodyl, Mg citrate) or enemas may disrupt
healing or cause discomfort.
10.A nurse is teaching a client without gout about dietary management. Which statement
indicates understanding?
- A. “I will eat more organ meats like liver.”
- B. “I should drink at least 2 liters of water daily.”
- C. “Sardines are a good source of protein for me.”
- D. “I can drink beer with meals.”
Rationale:B. “I should drink at least 2 liters of water daily.Hydration promotes uric acid
excretion. Organ meats, sardines, and alcohol (especially beer) are high in purines and worsen
gout.
11.A client is receiving IV heparin for deep vein thrombosis. The nurse notes a partial
thromboplastin time (PTT) of 110 seconds (control 30 seconds). What should the nurse do first?
- A. Continue monitoring as ordered
- B. Administer protamine sulfate
- C. Stop the heparin infusion
- D. Notify the healthcare provider
Rationale:C. Stop the heparin infusion.Therapeutic PTT for DVT is typically 1.5–2.5 times
control (~45–75 sec). 110 seconds is supratherapeutic and increases bleeding risk. Stop
infusion, then notify the provider.
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES A NEW UPDATED VERSION LATEST 2026-2027
(100% VERIFIED ANSWERS) GUARANTEED PASS A+
1.A client with heart failure is prescribed furosemide. Which assessment finding requires
immediate intervention?
- A. Weight loss of 1 kg in 24 hours
- B. Serum potassium level of 3.2 mEq/L
- C. Blood pressure of 110/70 mm Hg
- D. Urine output of 50 mL/hour
Rationale:B. Serum potassium level of 3.2 mEq/L.Furosemide is a loop diuretic that causes
potassium wasting. Hypokalemia (normal 3.5–5.0 mEq/L) increases the risk of digoxin toxicity
and cardiac arrhythmias. Weight loss of 1 kg is expected fluid loss. BP 110/70 is acceptable.
Urine output 50 mL/hr is adequate.
2. A postoperative client reports sudden chest pain and shortness of breath. The nurse notes
oxygen saturation of 88%. Which action should the nurse take first?
- A. Administer morphine sulfate
- B. Apply supplemental oxygen
- C. Obtain a STAT chest X-ray
- D. Elevate the head of the bed
Rationale:B. Apply supplemental oxygen.The priority is treating hypoxemia. Oxygen should be
applied immediately to maximize oxygen delivery. Elevating HOB helps but does not address
low SpO2 as urgently. Morphine and X-ray come after stabilization.
3. A client with cirrhosis has ascites and is receiving spironolactone. Which laboratory finding
indicates a therapeutic effect?
- A. Decreased serum sodium
,- B. Increased urine output
- C. Decreased serum ammonia
- D. Increased serum albumin
Rationale:B. Increased urine output.Spironolactone is a potassium-sparing diuretic used to
manage ascites by increasing urine output and reducing fluid retention. It does not directly
affect ammonia or albumin. Sodium may decrease if fluid shifts, but that is not the primary
therapeutic indicator.
4.A client on mechanical ventilation has a sudden decrease in oxygen saturation and absent
breath sounds on the right side. What should the nurse suspect?
- A. Pulmonary embolism
- B. Right-sided pneumothorax
- C. Mucus plug in the left mainstem bronchus
- D. Displaced endotracheal tube into the right mainstem bronchus
Rationale:B. Right-sided pneumothorax.Absent breath sounds unilaterally with desaturation
after sudden change suggests pneumothorax, especially if the client is on PEEP. Right mainstem
intubation would cause absent left breath sounds. Mucus plug would be gradual.
5.A client with type 1 diabetes mellitus is found unresponsive. Which intervention should be
implemented first?
- A. Check blood glucose level
- B. Administer glucagon IM
- C. Start IV dextrose 50%
- D. Assess airway and breathing
Rationale:D. Assess airway and breathing.ABCs always come first. After securing the airway,
then blood glucose and treatment for hypoglycemia (glucagon or IV dextrose) can be given.
6. A nurse is caring for a client receiving a blood transfusion. Fifteen minutes after initiation,
the client reports low back pain and chills. What is the priority action?
,- A. Slow the infusion rate
- B. Stop the transfusion
- C. Notify the healthcare provider
- D. Administer acetaminophen
Rationale:B. Stop the transfusion.These symptoms indicate a possible acute hemolytic reaction.
The transfusion must be stopped immediately to prevent further reaction. The IV line is kept
open with normal saline.
7. A client with major depressive disorder is started on phenelzine, an MAOI. Which food
should the nurse instruct the client to avoid?
- A. Apples
- B. Aged cheese
- C. White bread
- D. Broccoli
Rationale:B. Aged cheese.MAOIs can cause hypertensive crises when combined with
tyramine-rich foods (aged cheese, cured meats, fermented products). Apples, bread, and
broccoli are low in tyramine.
8. A client with chronic kidney disease has a potassium level of 6.1 mEq/L. Which
electrocardiogram change would the nurse expect?
- A. Flattened T waves
- B. Prominent U waves
- C. Peaked T waves
- D. Prolonged PR interval
Rationale:C. Peaked T waves.Hyperkalemia (>5.5 mEq/L) causes tall, peaked T waves,
widened QRS, and eventually sine wave pattern. Flattened T waves and U waves occur in
hypokalemia.
, 9.A postpartum client with a third-degree perineal laceration reports not having had a bowel
movement for 3 days. Which medication should the nurse anticipate?
- A. Bisacodyl suppository
- B. Docusate sodium
- C. Magnesium citrate
- D. Mineral oil enema
Rationale:B. Docusate sodium.Stool softener is preferred postpartum, especially with
lacerations, to prevent straining. Stimulants (bisacodyl, Mg citrate) or enemas may disrupt
healing or cause discomfort.
10.A nurse is teaching a client without gout about dietary management. Which statement
indicates understanding?
- A. “I will eat more organ meats like liver.”
- B. “I should drink at least 2 liters of water daily.”
- C. “Sardines are a good source of protein for me.”
- D. “I can drink beer with meals.”
Rationale:B. “I should drink at least 2 liters of water daily.Hydration promotes uric acid
excretion. Organ meats, sardines, and alcohol (especially beer) are high in purines and worsen
gout.
11.A client is receiving IV heparin for deep vein thrombosis. The nurse notes a partial
thromboplastin time (PTT) of 110 seconds (control 30 seconds). What should the nurse do first?
- A. Continue monitoring as ordered
- B. Administer protamine sulfate
- C. Stop the heparin infusion
- D. Notify the healthcare provider
Rationale:C. Stop the heparin infusion.Therapeutic PTT for DVT is typically 1.5–2.5 times
control (~45–75 sec). 110 seconds is supratherapeutic and increases bleeding risk. Stop
infusion, then notify the provider.
