BSN 366 EXIT HESI V2 | QUESTIONS AND CORRECT
ANSWERS WITH RATIONALE (ALREADY GRADED
A+) | LATEST UPDATE 2026/2027
The nurse assumes care of a postoperative adult client with type 2 diabetes
mellitus and learns that the client has a current blood glucose level of 720
mg/dL. When assessing the client, what is the priority?
A. Assess for signs of fluid volume deficit
B. Observe wound drainage characteristics
C. Measure the level of acute pain
D. Determine when the client last ate
Correct Answer: A. Assess for signs of fluid volume deficit
Rationale: A blood glucose level of 720 mg/dL indicates severe hyperglycemia,
which leads to osmotic diuresis. The kidneys excrete large amounts of glucose and
water, resulting in profound fluid volume deficit (hypovolemia). This can lead to
hypovolemic shock, electrolyte imbalances, and potentially death. The priority
assessment is to evaluate for signs of dehydration such as hypotension,
tachycardia, poor skin turgor, dry mucous membranes, and decreased urine
output. While assessing wound drainage, pain, and dietary history are important,
they are secondary to the life-threatening fluid volume deficit caused by extreme
hyperglycemia.
A male client tells the nurse that he is concerned that he may have a stomach
ulcer, because he is experiencing heartburn and dull gnawing pain that is
relieved when he eats. Which is the best response by the nurse?
A. Encourage the client to obtain a complete physical exam, since these symptoms
are consistent with an ulcer
B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is
not relieved with food
,C. Instruct the client that these mild symptoms can generally be controlled with
changes in his diet
D. Advise the client that he needs to seek immediate medical evaluation and
treatment of these symptoms
Correct Answer: A. Encourage the client to obtain a complete physical exam,
since these symptoms are consistent with an ulcer
Rationale: The client is describing classic symptoms of a duodenal ulcer:
heartburn and dull gnawing pain that is relieved by eating (food buffers stomach
acid). These symptoms warrant a complete physical examination and diagnostic
workup to confirm the diagnosis, identify the underlying cause (e.g., H. pylori
infection, NSAID use), and initiate appropriate treatment. Option B is incorrect
because ulcer pain IS typically relieved by food. Option C is inappropriate because
diet alone may not be sufficient, and symptoms should not be dismissed as "mild."
Option D overstates the urgency—while evaluation is needed, it is not necessarily
an emergency requiring immediate treatment.
A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a nasogastric tube to suction and is receiving Lactated
Ringer's solution at 75 mL/hr IV. One hour after admission to the unit, the nurse
notes 300 mL of blood in the suction canister, the client's heart rate is 155
beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting
the findings to the surgeon, which action should the nurse implement first?
A. Measure and document the client's urinary output
B. Request the client's reserved unit of packed red blood cells
C. Prepare for placement of a central venous catheter
D. Increase the infusion rate of Lactated Ringer's solution
Correct Answer: D. Increase the infusion rate of Lactated Ringer's solution
Rationale: The client is exhibiting signs of hypovolemic shock: tachycardia (155
bpm), hypotension (78/48 mmHg), and evidence of significant blood loss (300 mL
blood in suction canister). The priority intervention is to increase the IV fluid
infusion rate to restore intravascular volume and support blood pressure. This is a
,rapid, immediate action the nurse can take while awaiting further orders. While
requesting blood products, measuring urinary output, and preparing for central
line placement are all appropriate interventions, they are secondary to immediate
fluid resuscitation to prevent further hemodynamic compromise and organ
failure.
A heparin infusion is prescribed for a client who weighs 220 pounds. After
administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate
for the heparin solution as 18 units/kg/hour. The available solution is Heparin
Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program
the infusion pump to deliver how many mL/hour?
18
Correct Answer: 18 mL/hr
Rationale:
• Step 1: Convert weight to kg: 220 lbs ÷ 2.2 = 100 kg
• Step 2: Calculate dose in units/hr: 18 units/kg/hr × 100 kg = 1800 units/hr
• Step 3: Determine concentration: 25,000 units/250 mL = 100 units/mL
• Step 4: Calculate rate: 1800 units/hr ÷ 100 units/mL = 18 mL/hr
The nurse should program the pump to deliver 18 mL/hr.
An adult male who fell 20 feet from the roof of his home has multiple injuries,
including a right pneumothorax. Chest tubes were inserted in the emergency
department prior to his transfer to the intensive care unit (ICU). The nurse notes
that the suction control chamber is bubbling at the -10 cm H₂O mark, which
fluctuation in the water seal, and over the past hour 75 mL of bright red blood is
measured in the collection chamber. Which intervention should the nurse
implement?
A. Add sterile water to the suction control chamber
B. Give blood from the collection chamber as autotransfusion
, C. Manipulate blood in tubing to drain into chamber
D. Increase wall suction to eliminate fluctuation in water seal
Correct Answer: A. Add sterile water to the suction control chamber
Rationale: The suction control chamber should be filled with sterile water to the
prescribed level (typically -20 cm H₂O) to maintain appropriate suction pressure.
Bubbling at the -10 cm H₂O mark indicates the suction is functioning, but the fluid
level may be low. Adding sterile water maintains the water seal and ensures
proper suction. Option B is incorrect—blood from the collection chamber should
not be used for autotransfusion without specific protocols and filters. Option C is
incorrect—nurses should never "milk" or manipulate chest tube tubing as this can
create excessive negative pressure and damage lung tissue. Option D is
incorrect—fluctuation in the water seal is normal and indicates the system is
intact; increasing wall suction could cause tissue damage.
An adult male was diagnosed with stage IV lung cancer three weeks ago. His
wife approaches the nurse and asks how she will know that her husband's death
is imminent because their two adult children want to be there when he dies.
Which is the best response by the nurse?
A. Gather information regarding how long it will take for the children to arrive
B. Explain that the client will start to lose consciousness and the body systems will
slow down
C. Reassure the spouse that the healthcare provider will notify when to call the
children
D. Offer to discuss the client's health status with each of the adult children
Correct Answer: B. Explain that the client will start to lose consciousness and
the body systems will slow down
Rationale: This response provides honest, compassionate, and realistic
information about the dying process. It addresses the wife's question directly and
helps prepare the family for what to expect. The nurse should explain common
signs of impending death such as decreasing level of consciousness, slowed
respirations, decreased urine output, and cooling of extremities. Option A focuses
ANSWERS WITH RATIONALE (ALREADY GRADED
A+) | LATEST UPDATE 2026/2027
The nurse assumes care of a postoperative adult client with type 2 diabetes
mellitus and learns that the client has a current blood glucose level of 720
mg/dL. When assessing the client, what is the priority?
A. Assess for signs of fluid volume deficit
B. Observe wound drainage characteristics
C. Measure the level of acute pain
D. Determine when the client last ate
Correct Answer: A. Assess for signs of fluid volume deficit
Rationale: A blood glucose level of 720 mg/dL indicates severe hyperglycemia,
which leads to osmotic diuresis. The kidneys excrete large amounts of glucose and
water, resulting in profound fluid volume deficit (hypovolemia). This can lead to
hypovolemic shock, electrolyte imbalances, and potentially death. The priority
assessment is to evaluate for signs of dehydration such as hypotension,
tachycardia, poor skin turgor, dry mucous membranes, and decreased urine
output. While assessing wound drainage, pain, and dietary history are important,
they are secondary to the life-threatening fluid volume deficit caused by extreme
hyperglycemia.
A male client tells the nurse that he is concerned that he may have a stomach
ulcer, because he is experiencing heartburn and dull gnawing pain that is
relieved when he eats. Which is the best response by the nurse?
A. Encourage the client to obtain a complete physical exam, since these symptoms
are consistent with an ulcer
B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is
not relieved with food
,C. Instruct the client that these mild symptoms can generally be controlled with
changes in his diet
D. Advise the client that he needs to seek immediate medical evaluation and
treatment of these symptoms
Correct Answer: A. Encourage the client to obtain a complete physical exam,
since these symptoms are consistent with an ulcer
Rationale: The client is describing classic symptoms of a duodenal ulcer:
heartburn and dull gnawing pain that is relieved by eating (food buffers stomach
acid). These symptoms warrant a complete physical examination and diagnostic
workup to confirm the diagnosis, identify the underlying cause (e.g., H. pylori
infection, NSAID use), and initiate appropriate treatment. Option B is incorrect
because ulcer pain IS typically relieved by food. Option C is inappropriate because
diet alone may not be sufficient, and symptoms should not be dismissed as "mild."
Option D overstates the urgency—while evaluation is needed, it is not necessarily
an emergency requiring immediate treatment.
A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a nasogastric tube to suction and is receiving Lactated
Ringer's solution at 75 mL/hr IV. One hour after admission to the unit, the nurse
notes 300 mL of blood in the suction canister, the client's heart rate is 155
beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting
the findings to the surgeon, which action should the nurse implement first?
A. Measure and document the client's urinary output
B. Request the client's reserved unit of packed red blood cells
C. Prepare for placement of a central venous catheter
D. Increase the infusion rate of Lactated Ringer's solution
Correct Answer: D. Increase the infusion rate of Lactated Ringer's solution
Rationale: The client is exhibiting signs of hypovolemic shock: tachycardia (155
bpm), hypotension (78/48 mmHg), and evidence of significant blood loss (300 mL
blood in suction canister). The priority intervention is to increase the IV fluid
infusion rate to restore intravascular volume and support blood pressure. This is a
,rapid, immediate action the nurse can take while awaiting further orders. While
requesting blood products, measuring urinary output, and preparing for central
line placement are all appropriate interventions, they are secondary to immediate
fluid resuscitation to prevent further hemodynamic compromise and organ
failure.
A heparin infusion is prescribed for a client who weighs 220 pounds. After
administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate
for the heparin solution as 18 units/kg/hour. The available solution is Heparin
Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program
the infusion pump to deliver how many mL/hour?
18
Correct Answer: 18 mL/hr
Rationale:
• Step 1: Convert weight to kg: 220 lbs ÷ 2.2 = 100 kg
• Step 2: Calculate dose in units/hr: 18 units/kg/hr × 100 kg = 1800 units/hr
• Step 3: Determine concentration: 25,000 units/250 mL = 100 units/mL
• Step 4: Calculate rate: 1800 units/hr ÷ 100 units/mL = 18 mL/hr
The nurse should program the pump to deliver 18 mL/hr.
An adult male who fell 20 feet from the roof of his home has multiple injuries,
including a right pneumothorax. Chest tubes were inserted in the emergency
department prior to his transfer to the intensive care unit (ICU). The nurse notes
that the suction control chamber is bubbling at the -10 cm H₂O mark, which
fluctuation in the water seal, and over the past hour 75 mL of bright red blood is
measured in the collection chamber. Which intervention should the nurse
implement?
A. Add sterile water to the suction control chamber
B. Give blood from the collection chamber as autotransfusion
, C. Manipulate blood in tubing to drain into chamber
D. Increase wall suction to eliminate fluctuation in water seal
Correct Answer: A. Add sterile water to the suction control chamber
Rationale: The suction control chamber should be filled with sterile water to the
prescribed level (typically -20 cm H₂O) to maintain appropriate suction pressure.
Bubbling at the -10 cm H₂O mark indicates the suction is functioning, but the fluid
level may be low. Adding sterile water maintains the water seal and ensures
proper suction. Option B is incorrect—blood from the collection chamber should
not be used for autotransfusion without specific protocols and filters. Option C is
incorrect—nurses should never "milk" or manipulate chest tube tubing as this can
create excessive negative pressure and damage lung tissue. Option D is
incorrect—fluctuation in the water seal is normal and indicates the system is
intact; increasing wall suction could cause tissue damage.
An adult male was diagnosed with stage IV lung cancer three weeks ago. His
wife approaches the nurse and asks how she will know that her husband's death
is imminent because their two adult children want to be there when he dies.
Which is the best response by the nurse?
A. Gather information regarding how long it will take for the children to arrive
B. Explain that the client will start to lose consciousness and the body systems will
slow down
C. Reassure the spouse that the healthcare provider will notify when to call the
children
D. Offer to discuss the client's health status with each of the adult children
Correct Answer: B. Explain that the client will start to lose consciousness and
the body systems will slow down
Rationale: This response provides honest, compassionate, and realistic
information about the dying process. It addresses the wife's question directly and
helps prepare the family for what to expect. The nurse should explain common
signs of impending death such as decreasing level of consciousness, slowed
respirations, decreased urine output, and cooling of extremities. Option A focuses
