EXAM HESI RN EXIT EXAM TEST BANK (LATEST UPDATED, )( Q & A) (VERIFIED BATON ROUGE COMMUNITY
COLLEGE NURSING MED-SURGE HESI EXIT EXAM QUESTIONS AND ANSWERS ALREADY GRADED A+. 100%
VERIFIED SOLUTIONS | UPDATED PER LATEST GUIDELINES | GRADED A+...
Question 1
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which finding indicates a
need for immediate intervention?
A. Fasting blood glucose of 140 mg/dL
B. Fruity breath odor and Kussmaul respirations
C. Mild polyuria and polydipsia
D. Glycosylated hemoglobin of 7.5%
🟢 Correct Answer:
B. Fruity breath odor and Kussmaul respirations
🔴 RATIONALE:
Fruity breath odor and Kussmaul respirations are signs of diabetic ketoacidosis, a life-threatening complication
requiring immediate intervention. A fasting glucose of 140 mg/dL is elevated but not emergent; mild polyuria
and polydipsia are common manifestations; an HbA1c of 7.5% indicates suboptimal but not immediate risk.
Question 2
A client with heart failure is receiving furosemide. Which laboratory value is most important for the nurse to
monitor?
A. Serum sodium
B. Serum potassium
,C. Serum calcium
D. Serum magnesium
🟢 Correct Answer:
B. Serum potassium
🔴 RATIONALE:
Furosemide is a loop diuretic that promotes potassium excretion, placing the client at risk for hypokalemia and
cardiac dysrhythmias. Serum potassium must be monitored closely. Sodium, calcium, and magnesium are less
directly affected by furosemide.
Question 3
A nurse is assessing a client who has fluid volume excess. Which finding should the nurse expect?
A. Orthostatic hypotension
B. Jugular venous distention
C. Poor skin turgor
D. Dry mucous membranes
🟢 Correct Answer:
B. Jugular venous distention
🔴 RATIONALE:
Fluid volume excess causes increased venous pressure, leading to jugular venous distention. Orthostatic
hypotension, poor skin turgor, and dry mucous membranes are findings associated with fluid volume deficit.
Question 4
A client is receiving a blood transfusion. Within 15 minutes, the client develops chills, flank pain, and fever. What
,is the nurse's priority action?
A. Slow the transfusion and reassess in 30 minutes
B. Stop the transfusion, maintain the IV line with normal saline, and notify the provider
C. Administer an antipyretic and continue the transfusion
D. Flush the blood tubing with normal saline to clear the line
🟢 Correct Answer:
B. Stop the transfusion, maintain the IV line with normal saline, and notify the provider
🔴 RATIONALE:
Chills, flank pain, and fever suggest an acute hemolytic transfusion reaction. The priority is to stop the
transfusion immediately, keep the vein open with normal saline, and notify the provider. Slowing or continuing
the transfusion worsens the reaction; flushing the blood tubing may introduce additional incompatible blood.
Question 5
A nurse is caring for a client who has a new tracheostomy. Which action is most important in the first 24 hours?
A. Maintain the trach ties tight to prevent dislodgement
B. Assess the patency of the airway and monitor for bleeding or subcutaneous emphysema
C. Provide oral feedings immediately
D. Remove the outer cannula for cleaning each shift
🟢 Correct Answer:
B. Assess the patency of the airway and monitor for bleeding or subcutaneous emphysema
🔴 RATIONALE:
In the first 24 hours after tracheostomy placement, the nurse must monitor for airway patency, bleeding, and
, subcutaneous emphysema. Ties should be secure but not too tight. Oral feedings require careful assessment.
The outer cannula should not be removed for cleaning in the first 24 hours.
Question 6
A client with a nasogastric tube connected to low intermittent suction is at risk for which acid-base imbalance?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
🟢 Correct Answer:
B. Metabolic alkalosis
🔴 RATIONALE:
Nasogastric suction removes hydrochloric acid from the stomach, leading to metabolic alkalosis. Metabolic
acidosis results from base loss or acid gain; respiratory imbalances are not directly caused by gastric suctioning.
Question 7
A nurse is assessing a client who has an IV infusion in the left forearm. The site is swollen, cool, pale, and
painful. What is the priority action?
A. Slow the infusion rate and elevate the arm
B. Apply a warm compress and continue monitoring
C. Stop the infusion and discontinue the IV catheter
D. Flush the catheter with normal saline to assess patency
🟢 Correct Answer:
C. Stop the infusion and discontinue the IV catheter
COLLEGE NURSING MED-SURGE HESI EXIT EXAM QUESTIONS AND ANSWERS ALREADY GRADED A+. 100%
VERIFIED SOLUTIONS | UPDATED PER LATEST GUIDELINES | GRADED A+...
Question 1
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which finding indicates a
need for immediate intervention?
A. Fasting blood glucose of 140 mg/dL
B. Fruity breath odor and Kussmaul respirations
C. Mild polyuria and polydipsia
D. Glycosylated hemoglobin of 7.5%
🟢 Correct Answer:
B. Fruity breath odor and Kussmaul respirations
🔴 RATIONALE:
Fruity breath odor and Kussmaul respirations are signs of diabetic ketoacidosis, a life-threatening complication
requiring immediate intervention. A fasting glucose of 140 mg/dL is elevated but not emergent; mild polyuria
and polydipsia are common manifestations; an HbA1c of 7.5% indicates suboptimal but not immediate risk.
Question 2
A client with heart failure is receiving furosemide. Which laboratory value is most important for the nurse to
monitor?
A. Serum sodium
B. Serum potassium
,C. Serum calcium
D. Serum magnesium
🟢 Correct Answer:
B. Serum potassium
🔴 RATIONALE:
Furosemide is a loop diuretic that promotes potassium excretion, placing the client at risk for hypokalemia and
cardiac dysrhythmias. Serum potassium must be monitored closely. Sodium, calcium, and magnesium are less
directly affected by furosemide.
Question 3
A nurse is assessing a client who has fluid volume excess. Which finding should the nurse expect?
A. Orthostatic hypotension
B. Jugular venous distention
C. Poor skin turgor
D. Dry mucous membranes
🟢 Correct Answer:
B. Jugular venous distention
🔴 RATIONALE:
Fluid volume excess causes increased venous pressure, leading to jugular venous distention. Orthostatic
hypotension, poor skin turgor, and dry mucous membranes are findings associated with fluid volume deficit.
Question 4
A client is receiving a blood transfusion. Within 15 minutes, the client develops chills, flank pain, and fever. What
,is the nurse's priority action?
A. Slow the transfusion and reassess in 30 minutes
B. Stop the transfusion, maintain the IV line with normal saline, and notify the provider
C. Administer an antipyretic and continue the transfusion
D. Flush the blood tubing with normal saline to clear the line
🟢 Correct Answer:
B. Stop the transfusion, maintain the IV line with normal saline, and notify the provider
🔴 RATIONALE:
Chills, flank pain, and fever suggest an acute hemolytic transfusion reaction. The priority is to stop the
transfusion immediately, keep the vein open with normal saline, and notify the provider. Slowing or continuing
the transfusion worsens the reaction; flushing the blood tubing may introduce additional incompatible blood.
Question 5
A nurse is caring for a client who has a new tracheostomy. Which action is most important in the first 24 hours?
A. Maintain the trach ties tight to prevent dislodgement
B. Assess the patency of the airway and monitor for bleeding or subcutaneous emphysema
C. Provide oral feedings immediately
D. Remove the outer cannula for cleaning each shift
🟢 Correct Answer:
B. Assess the patency of the airway and monitor for bleeding or subcutaneous emphysema
🔴 RATIONALE:
In the first 24 hours after tracheostomy placement, the nurse must monitor for airway patency, bleeding, and
, subcutaneous emphysema. Ties should be secure but not too tight. Oral feedings require careful assessment.
The outer cannula should not be removed for cleaning in the first 24 hours.
Question 6
A client with a nasogastric tube connected to low intermittent suction is at risk for which acid-base imbalance?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
🟢 Correct Answer:
B. Metabolic alkalosis
🔴 RATIONALE:
Nasogastric suction removes hydrochloric acid from the stomach, leading to metabolic alkalosis. Metabolic
acidosis results from base loss or acid gain; respiratory imbalances are not directly caused by gastric suctioning.
Question 7
A nurse is assessing a client who has an IV infusion in the left forearm. The site is swollen, cool, pale, and
painful. What is the priority action?
A. Slow the infusion rate and elevate the arm
B. Apply a warm compress and continue monitoring
C. Stop the infusion and discontinue the IV catheter
D. Flush the catheter with normal saline to assess patency
🟢 Correct Answer:
C. Stop the infusion and discontinue the IV catheter
