HESI RN Exit V2 Study Guide Latest Update 2026 | Pass
Exam Prep
1. Why is it critical for the nurse to administer supplemental oxygen to a client
with an oxygen saturation of 89%?
Administering supplemental oxygen helps to improve the client's
oxygen saturation and alleviate shortness of breath.
Administering supplemental oxygen is only needed if the client is
unconscious.
Administering supplemental oxygen is necessary to lower blood
pressure.
Administering supplemental oxygen prevents fluid overload.
2. When assessing a 6-month old infant, the nurse determines that the anterior
fontanel is bulging. In which situation would this finding be most significant?
Straining on stool
Crying
Sitting upright.
Vomiting
3. A client has a living will and an advance directive specifying no intubation or
CPR. The client's spouse and children tell the nurse privately that they want
the client resuscitated, if the need arises. How should the nurse respond?
Nurses use their best judgment based on the client's condition.
The healthcare team must honor the written wishes of the client.
Every effort must be made to honor the family's wishes about their
loved one.
, Notify the healthcare provider of the family's wishes, so a decision can
be made.
4. Why is dizziness upon standing a concerning symptom for a patient 24 hours
post-surgery?
It is a normal response to anesthesia and not a concern.
It indicates that the patient is recovering well from surgery.
It may indicate a drop in blood pressure, which can lead to falls and
further complications.
It suggests the patient is dehydrated and needs fluids.
5. Why is it important for the nurse to assess the delivery mechanism of the
oxygen before taking other actions in a client with COPD?
It allows the nurse to check for any underlying lung conditions.
It helps the nurse understand the client's emotional state during
distress.
It provides insight into the client's medication adherence.
Assessing the delivery mechanism ensures that the client is
receiving the correct amount of oxygen, which is critical for
managing their respiratory distress.
6. The nurse is caring for a client at home who has chronic COPD and is
receiving oxygen at 2 L per minute. The clients Respiratory rate is 22 breaths
per minute. The clients Respiratory rate is 22 breaths per minute, and the
client is complaining of increased dyspnea. The nurse should take which initial
action?
Call emergency services to come to the home
Reassure the client that there is no need to worry
, Collect more information about the clients Respiratory status
Determine the need to increase oxygen
7. What is the primary nursing intervention for a client with Kaposi's sarcoma
and a history of intravenous drug use?
Observe for adverse drug reactions
Assess for symptoms of AIDS dementia
Identify local HIV support groups
Monitor for secondary infections
8. A nurse withholds methylergonovine maleate (Methergine) from a
postpartum client. What clinical finding supports the withholding of the
medication?
Third-degree perineal laceration
Blood pressure of 160/90 mm Hg
Urine output of 50 mL/hr
Respiratory rate of 12 breaths/min
9. Why is it important for the nurse to have the client vocalize the instructions
after cataract surgery?
It provides an opportunity for the nurse to educate the family instead.
It allows the nurse to avoid repeating the instructions.
It ensures the client feels comfortable with the discharge process.
It confirms the client's understanding and ability to follow self-care
instructions.
, 10. In a scenario where an older client presents with both skin tenting and a high
urine specific gravity, what should the nurse prioritize in their care plan?
Fluid replacement therapy
Administering diuretics
Increasing dietary sodium intake
Monitoring blood pressure only
11. An older woman w/ a history of atrial fibrillation fell at home and fractured
her left hip. She is currently taking warfarin 5 mg daily and has an INR value
of 5.0. Upon admission, which prescription should the nurse expect to
implement?
Transfusion unit of packed RBCs
Administer Vitamin K injection
Start continuous heparin infusion
Continue warfarin at same dose
12. What is the recommended action for a patient with an INR value of 5.0 who
is on warfarin?
Continue warfarin at same dose
Administer Vitamin K injection
Start continuous heparin infusion
Transfuse unit of packed red blood cells
13. In a scenario where a toddler receiving oxygen via face mask develops
further skin irritation despite using a lubricant, what should the nurse
consider next?
Exam Prep
1. Why is it critical for the nurse to administer supplemental oxygen to a client
with an oxygen saturation of 89%?
Administering supplemental oxygen helps to improve the client's
oxygen saturation and alleviate shortness of breath.
Administering supplemental oxygen is only needed if the client is
unconscious.
Administering supplemental oxygen is necessary to lower blood
pressure.
Administering supplemental oxygen prevents fluid overload.
2. When assessing a 6-month old infant, the nurse determines that the anterior
fontanel is bulging. In which situation would this finding be most significant?
Straining on stool
Crying
Sitting upright.
Vomiting
3. A client has a living will and an advance directive specifying no intubation or
CPR. The client's spouse and children tell the nurse privately that they want
the client resuscitated, if the need arises. How should the nurse respond?
Nurses use their best judgment based on the client's condition.
The healthcare team must honor the written wishes of the client.
Every effort must be made to honor the family's wishes about their
loved one.
, Notify the healthcare provider of the family's wishes, so a decision can
be made.
4. Why is dizziness upon standing a concerning symptom for a patient 24 hours
post-surgery?
It is a normal response to anesthesia and not a concern.
It indicates that the patient is recovering well from surgery.
It may indicate a drop in blood pressure, which can lead to falls and
further complications.
It suggests the patient is dehydrated and needs fluids.
5. Why is it important for the nurse to assess the delivery mechanism of the
oxygen before taking other actions in a client with COPD?
It allows the nurse to check for any underlying lung conditions.
It helps the nurse understand the client's emotional state during
distress.
It provides insight into the client's medication adherence.
Assessing the delivery mechanism ensures that the client is
receiving the correct amount of oxygen, which is critical for
managing their respiratory distress.
6. The nurse is caring for a client at home who has chronic COPD and is
receiving oxygen at 2 L per minute. The clients Respiratory rate is 22 breaths
per minute. The clients Respiratory rate is 22 breaths per minute, and the
client is complaining of increased dyspnea. The nurse should take which initial
action?
Call emergency services to come to the home
Reassure the client that there is no need to worry
, Collect more information about the clients Respiratory status
Determine the need to increase oxygen
7. What is the primary nursing intervention for a client with Kaposi's sarcoma
and a history of intravenous drug use?
Observe for adverse drug reactions
Assess for symptoms of AIDS dementia
Identify local HIV support groups
Monitor for secondary infections
8. A nurse withholds methylergonovine maleate (Methergine) from a
postpartum client. What clinical finding supports the withholding of the
medication?
Third-degree perineal laceration
Blood pressure of 160/90 mm Hg
Urine output of 50 mL/hr
Respiratory rate of 12 breaths/min
9. Why is it important for the nurse to have the client vocalize the instructions
after cataract surgery?
It provides an opportunity for the nurse to educate the family instead.
It allows the nurse to avoid repeating the instructions.
It ensures the client feels comfortable with the discharge process.
It confirms the client's understanding and ability to follow self-care
instructions.
, 10. In a scenario where an older client presents with both skin tenting and a high
urine specific gravity, what should the nurse prioritize in their care plan?
Fluid replacement therapy
Administering diuretics
Increasing dietary sodium intake
Monitoring blood pressure only
11. An older woman w/ a history of atrial fibrillation fell at home and fractured
her left hip. She is currently taking warfarin 5 mg daily and has an INR value
of 5.0. Upon admission, which prescription should the nurse expect to
implement?
Transfusion unit of packed RBCs
Administer Vitamin K injection
Start continuous heparin infusion
Continue warfarin at same dose
12. What is the recommended action for a patient with an INR value of 5.0 who
is on warfarin?
Continue warfarin at same dose
Administer Vitamin K injection
Start continuous heparin infusion
Transfuse unit of packed red blood cells
13. In a scenario where a toddler receiving oxygen via face mask develops
further skin irritation despite using a lubricant, what should the nurse
consider next?
