PN HESI EXIT EXAM V1 NEWEST 2026 ACTUAL
EXAM| ELSEVIER HESI PN EXIT EXAM V1 WITH
COMPLETE 150 REAL EXAM QUESTIONS AND
CORRECT VERIFIED ANSWERS/ ALREADY GRADED
A+ (MOST RECENT!!)
A male client is admitted for observation after being hit on the head with
a baseball bat. Six hours after admission, the client attempts to crawl out
of bed and asks the nurse why there are so many bugs in his bed. His
vital signs are stable, and the pulse oximeter reading is 98% on room air.
Which intervention should the nurse perform first?
A.Administer oxygen per nasal cannula at 2 L/min.
B.Plan to check his vital signs again in 30 minutes.
C.Notify the health care provider of the change in mental status.
D.Ask the client why he thinks there are bugs in the bed. - Correct
Answer - C
One of the earliest signs of increased intracranial pressure (ICP) is a
change in mental status (C). It is important to act early and quickly when
symptoms of increased ICP occur. Because his oxygen saturation is
normal.
The nurse is monitoring a client who is receiving bedside conscious
sedation with midazolam hydrochloride (Versed). In assessing the client,
the nurse determines that the client has slurred speech with diplopia.
Based on this finding, what action should the nurse take?
A.Open the airway with a chin lift-head tilt maneuver.
B.Obtain a fingerstick glucose reading.
C.Administer flumazenil (Romazicon).
pg. 1
,D.Continue to monitor the client. - Correct Answer - D
The desired level III in conscious sedation includes slurred speech,
glazed eyes, and marked diplopia. Because this is the desired outcome of
the medication regimen, no action is needed but continuing to monitor
the client (D).
A client with small cell carcinoma of the lung has also developed
syndrome of inappropriate antidiuretic hormone (SIADH). Which
outcome finding is the priority for this client?
A.Reduced peripheral edema
B.Urinary output of at least 70 mL/hr
C.Decrease in urine osmolarity
D.Serum sodium level of 137 mEq/L - Correct Answer - D
Syndrome of inappropriate antidiuretic hormone (SIADH) results from
an abnormal production or sustained secretion of antidiuretic hormone,
causing fluid retention, hyponatremia, and central nervous system (CNS)
fluid shifts. The client's normalization of the serum sodium level (normal
is 135 to 145 mEq/L) (D) is the most important outcome because sudden
and severe hyponatremia caused by fluid overload can result in heart
failure.
Which assessment finding indicates that nystatin (Mycostatin) swish and
swallow, prescribed for a client with oral candidiasis, has been effective?
A.The client denies dysphagia.
B.The client is afebrile with warm and dry skin.
C.The oral mucosa is pink and intact.
D.There is no reflux following food intake. - Correct Answer - C
pg. 2
,Mycostatin swish and swallow is prescribed for its local effect on the
oral mucosa, reducing the white curdlike lesions in the mouth and larynx
The health care provider prescribes 1000 mL of Ringer's lactate solution
with 30 units of oxytocin (Pitocin) to infuse over 4 hours for a client
who has just delivered a 10-lb infant by cesarean section. The tubing has
been changed to a 20 gtt/mL administration set. The nurse should set the
flow rate at how many gtt/min?
A.42
B.83
C.125
D.250 - Correct Answer - B
Use the following calculation:
20 gtt/mL × (1000 mL/4 hr) × (1 hr/60 min) = 83 gtt/min
Prior to administering an oral suspension, which intervention is most
important for the nurse to implement?
A.Assess the client's ability to swallow liquids.
B.Obtain applesauce in which to mix the medication.
C.Determine the client's food likes and dislikes.
D.Auscultate the client's breath sounds. - Correct Answer - A
An oral suspension is a liquid, so the nurse needs to assess the client's
ability to swallow liquids (A) to ensure that the client will not choke.
A comatose client is admitted to the critical care unit and a central
venous catheter is inserted by the health care provider. What is the
priority nursing assessment before initiating IV fluids?
pg. 3
, A.Pain scale
B.Vital signs
C.Breath sounds
D.Level of consciousness - Correct Answer - C
Before administering IV fluids through a central line, the nurse must
first ensure that the catheter did not puncture the vessel or lungs. A chest
radiograph should be obtained STAT, and the nurse should auscultate the
client's breath sounds (C).
The nurse is correct in withholding an older adult client's dose of
nifedipine (Procardia) if which assessment finding is obtained?
A.Blood pressure of 90/56 mm Hg
B.Apical pulse rate of 68 beats/min
C.Potassium level of 3.3 mEq/L
D.Urine output of 200 mL in 4 hours - Correct Answer - A
Nifedipine (Procardia) is a calcium channel blocker that causes a
decrease in blood pressure. It should be withheld if the blood pressure is
lowered, and 90/56 mm Hg is a low blood pressure for an adult male.
A client hospitalized for meningitis is demonstrating nuchal rigidity.
Which symptom is this client likely to be exhibiting?
A.Hyperexcitability of reflexes
B.Hyperextension of the head and back
C.Inability to flex the chin to the chest
D.Lateral facial paralysis - Correct Answer - C
pg. 4
EXAM| ELSEVIER HESI PN EXIT EXAM V1 WITH
COMPLETE 150 REAL EXAM QUESTIONS AND
CORRECT VERIFIED ANSWERS/ ALREADY GRADED
A+ (MOST RECENT!!)
A male client is admitted for observation after being hit on the head with
a baseball bat. Six hours after admission, the client attempts to crawl out
of bed and asks the nurse why there are so many bugs in his bed. His
vital signs are stable, and the pulse oximeter reading is 98% on room air.
Which intervention should the nurse perform first?
A.Administer oxygen per nasal cannula at 2 L/min.
B.Plan to check his vital signs again in 30 minutes.
C.Notify the health care provider of the change in mental status.
D.Ask the client why he thinks there are bugs in the bed. - Correct
Answer - C
One of the earliest signs of increased intracranial pressure (ICP) is a
change in mental status (C). It is important to act early and quickly when
symptoms of increased ICP occur. Because his oxygen saturation is
normal.
The nurse is monitoring a client who is receiving bedside conscious
sedation with midazolam hydrochloride (Versed). In assessing the client,
the nurse determines that the client has slurred speech with diplopia.
Based on this finding, what action should the nurse take?
A.Open the airway with a chin lift-head tilt maneuver.
B.Obtain a fingerstick glucose reading.
C.Administer flumazenil (Romazicon).
pg. 1
,D.Continue to monitor the client. - Correct Answer - D
The desired level III in conscious sedation includes slurred speech,
glazed eyes, and marked diplopia. Because this is the desired outcome of
the medication regimen, no action is needed but continuing to monitor
the client (D).
A client with small cell carcinoma of the lung has also developed
syndrome of inappropriate antidiuretic hormone (SIADH). Which
outcome finding is the priority for this client?
A.Reduced peripheral edema
B.Urinary output of at least 70 mL/hr
C.Decrease in urine osmolarity
D.Serum sodium level of 137 mEq/L - Correct Answer - D
Syndrome of inappropriate antidiuretic hormone (SIADH) results from
an abnormal production or sustained secretion of antidiuretic hormone,
causing fluid retention, hyponatremia, and central nervous system (CNS)
fluid shifts. The client's normalization of the serum sodium level (normal
is 135 to 145 mEq/L) (D) is the most important outcome because sudden
and severe hyponatremia caused by fluid overload can result in heart
failure.
Which assessment finding indicates that nystatin (Mycostatin) swish and
swallow, prescribed for a client with oral candidiasis, has been effective?
A.The client denies dysphagia.
B.The client is afebrile with warm and dry skin.
C.The oral mucosa is pink and intact.
D.There is no reflux following food intake. - Correct Answer - C
pg. 2
,Mycostatin swish and swallow is prescribed for its local effect on the
oral mucosa, reducing the white curdlike lesions in the mouth and larynx
The health care provider prescribes 1000 mL of Ringer's lactate solution
with 30 units of oxytocin (Pitocin) to infuse over 4 hours for a client
who has just delivered a 10-lb infant by cesarean section. The tubing has
been changed to a 20 gtt/mL administration set. The nurse should set the
flow rate at how many gtt/min?
A.42
B.83
C.125
D.250 - Correct Answer - B
Use the following calculation:
20 gtt/mL × (1000 mL/4 hr) × (1 hr/60 min) = 83 gtt/min
Prior to administering an oral suspension, which intervention is most
important for the nurse to implement?
A.Assess the client's ability to swallow liquids.
B.Obtain applesauce in which to mix the medication.
C.Determine the client's food likes and dislikes.
D.Auscultate the client's breath sounds. - Correct Answer - A
An oral suspension is a liquid, so the nurse needs to assess the client's
ability to swallow liquids (A) to ensure that the client will not choke.
A comatose client is admitted to the critical care unit and a central
venous catheter is inserted by the health care provider. What is the
priority nursing assessment before initiating IV fluids?
pg. 3
, A.Pain scale
B.Vital signs
C.Breath sounds
D.Level of consciousness - Correct Answer - C
Before administering IV fluids through a central line, the nurse must
first ensure that the catheter did not puncture the vessel or lungs. A chest
radiograph should be obtained STAT, and the nurse should auscultate the
client's breath sounds (C).
The nurse is correct in withholding an older adult client's dose of
nifedipine (Procardia) if which assessment finding is obtained?
A.Blood pressure of 90/56 mm Hg
B.Apical pulse rate of 68 beats/min
C.Potassium level of 3.3 mEq/L
D.Urine output of 200 mL in 4 hours - Correct Answer - A
Nifedipine (Procardia) is a calcium channel blocker that causes a
decrease in blood pressure. It should be withheld if the blood pressure is
lowered, and 90/56 mm Hg is a low blood pressure for an adult male.
A client hospitalized for meningitis is demonstrating nuchal rigidity.
Which symptom is this client likely to be exhibiting?
A.Hyperexcitability of reflexes
B.Hyperextension of the head and back
C.Inability to flex the chin to the chest
D.Lateral facial paralysis - Correct Answer - C
pg. 4
