HESI RN EXIT EXAM VERSION 3 ACTUAL EXAM WITH 160
QUESTION AND CORRECT DETAILED ANSWERS WITH
RATIONALES.
QUESTION 1
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/hour 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 finding 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 the placement of a central venous catheter.
d. Increase the infusion rate of Lactated Ringer's solution.
CORRECT ANS: d. Increase the infusion rate of Lactated Ringer's solution.
Expert Rationale
The client is exhibiting classic signs of hypovolemic shock: tachycardia (155 bpm),
hypotension (78/48 mmHg), and evidence of significant blood loss (300 mL in the suction
canister in one hour). Following a total gastrectomy, there is a high risk of hemorrhage.
The immediate priority is to restore intravascular volume to maintain perfusion to vital
organs. Increasing the infusion rate of Lactated Ringer's solution is the first and most
critical intervention to support blood pressure and cardiac output. While reporting the
finding to the surgeon is essential, the nurse must act immediately to treat the shock
before the surgeon can intervene. The crystalloid solution will help maintain blood
pressure until blood products can be administered. Measuring urinary output (a) is
important for assessing renal perfusion but is not the first action. Requesting blood
products (b) and preparing for a central venous catheter (c) are important but secondary
to immediate fluid resuscitation.
DIF: Cognitive Level: Apply (Application)
TOP: Surgical Nursing - Hemorrhage
MSC: HESI RN Exit Exam
,QUESTION 2
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, with 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 ANS: a. Add sterile water to the suction control chamber.
Expert Rationale
The suction control chamber in a chest tube drainage system is used to regulate the
amount of suction applied. The chamber should be filled with sterile water to the
prescribed level (typically 20 cm H2O). Bubbling at the -10 cm H2O mark indicates that
the suction is set to -10 cm H2O, which may be too low for effective lung re-expansion.
The nurse should add sterile water to the suction control chamber to achieve the
prescribed level. Fluctuation in the water seal is a normal finding indicating that the chest
tube is patent and the lung is re-expanding. 75 mL of bright red blood is concerning but
may be expected immediately post-insertion; continued monitoring is needed, but the
suction level needs to be corrected first. Autotransfusion (b) would require specific orders
and is not a priority. Manipulating blood in the tubing (c) is not appropriate. Increasing
wall suction (d) is contraindicated and could cause tissue damage.
DIF: Cognitive Level: Apply (Application)
TOP: Chest Tube Management - Suction Control
MSC: HESI RN Exit Exam
QUESTION 3
A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100
mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is
manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on
room air of 89%. Which action should the nurse take first?
,a. Elevate the foot of the bed.
b. Restrict the client's fluid.
c. Begin supplemental oxygen.
d. Prepare the client for hemodialysis.
CORRECT ANS: c. Begin supplemental oxygen.
Expert Rationale
The client is exhibiting signs of fluid overload and pulmonary edema, characterized by
hypertension, tachycardia, tachypnea, shortness of breath, edema, and hypoxemia (SpO2
89%). This is a life-threatening emergency following hemodialysis, likely due to fluid
volume excess or inadequate fluid removal during dialysis. The priority intervention is to
address the hypoxemia by beginning supplemental oxygen to improve oxygenation and
prevent further respiratory compromise. While other interventions such as diuretics or
repositioning may be necessary, oxygen administration is the immediate priority to
maintain adequate tissue oxygenation. Elevating the foot of the bed (a) would worsen the
condition. Restricting fluid (b) and preparing for dialysis (d) are important but secondary
to oxygen administration.
DIF: Cognitive Level: Apply (Application)
TOP: Renal Nursing - Hemodialysis Complications
MSC: HESI RN Exit Exam
QUESTION 4
A client with Addison's crisis is admitted for treatment with adrenal cortical
supplementation. Based on the client's admitting diagnosis, which findings require
immediate action by the nurse? (Select all that apply.)
a. Headache and tremors
b. Irregular heart rate
c. Skin hyperpigmentation
d. Postural hypotension
e. Pallor and diaphoresis
CORRECT ANS: a. Headache and tremors; b. Irregular heart rate; d. Postural hypotension;
e. Pallor and diaphoresis
Expert Rationale
Addison's crisis is a life-threatening condition caused by acute adrenal insufficiency. It is
characterized by severe hypotension, dehydration, hypoglycemia, and electrolyte
imbalances (hyponatremia and hyperkalemia). The manifestations include headache and
, tremors (a) (due to hypoglycemia), irregular heart rate (b) (due to hyperkalemia), postural
hypotension (d), and pallor and diaphoresis (e) (due to hypotension and shock). These
findings indicate that the client is in crisis and require immediate action, including
administration of IV corticosteroids, IV fluids, and glucose. Skin hyperpigmentation (c) is a
chronic sign of Addison's disease and is not an acute finding requiring immediate action.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Endocrine Nursing - Addison's Crisis
MSC: HESI RN Exit Exam
QUESTION 5
An older client is admitted with fluid volume deficit and dehydration. Which assessment
finding is the best indicator of hydration that the nurse should report to the healthcare
provider?
a. Urine specific gravity is 1.040
b. Systolic blood pressure decreases 10 points when standing.
c. The client denies being thirsty.
d. Skin tenting occurs when the client's forearm is pinched.
CORRECT ANS: d. Skin tenting occurs when the client's forearm is pinched.
Expert Rationale
Skin tenting (loss of skin turgor) is a classic sign of dehydration. When the skin is pinched
and fails to return to its normal position, it indicates a loss of interstitial fluid. This finding
is a reliable indicator of fluid volume deficit, especially in older adults. The forearm is a
more reliable site for assessing skin turgor in older adults than the sternum or back of the
hand, as skin elasticity is often decreased due to aging. Reporting skin tenting to the
healthcare provider provides objective data to support the diagnosis and guide fluid
replacement therapy. A urine specific gravity of 1.040 (a) indicates concentrated urine,
which can be a sign of dehydration, but skin tenting is a more direct indicator of
extracellular fluid loss. Orthostatic hypotension (b) is a sign of dehydration but can be
influenced by other factors. The client denying thirst (c) is not a reliable indicator, as older
adults often have a decreased thirst mechanism.
DIF: Cognitive Level: Apply (Application)
TOP: Fluid and Electrolyte Balance - Dehydration
MSC: HESI RN Exit Exam
QUESTION AND CORRECT DETAILED ANSWERS WITH
RATIONALES.
QUESTION 1
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/hour 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 finding 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 the placement of a central venous catheter.
d. Increase the infusion rate of Lactated Ringer's solution.
CORRECT ANS: d. Increase the infusion rate of Lactated Ringer's solution.
Expert Rationale
The client is exhibiting classic signs of hypovolemic shock: tachycardia (155 bpm),
hypotension (78/48 mmHg), and evidence of significant blood loss (300 mL in the suction
canister in one hour). Following a total gastrectomy, there is a high risk of hemorrhage.
The immediate priority is to restore intravascular volume to maintain perfusion to vital
organs. Increasing the infusion rate of Lactated Ringer's solution is the first and most
critical intervention to support blood pressure and cardiac output. While reporting the
finding to the surgeon is essential, the nurse must act immediately to treat the shock
before the surgeon can intervene. The crystalloid solution will help maintain blood
pressure until blood products can be administered. Measuring urinary output (a) is
important for assessing renal perfusion but is not the first action. Requesting blood
products (b) and preparing for a central venous catheter (c) are important but secondary
to immediate fluid resuscitation.
DIF: Cognitive Level: Apply (Application)
TOP: Surgical Nursing - Hemorrhage
MSC: HESI RN Exit Exam
,QUESTION 2
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, with 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 ANS: a. Add sterile water to the suction control chamber.
Expert Rationale
The suction control chamber in a chest tube drainage system is used to regulate the
amount of suction applied. The chamber should be filled with sterile water to the
prescribed level (typically 20 cm H2O). Bubbling at the -10 cm H2O mark indicates that
the suction is set to -10 cm H2O, which may be too low for effective lung re-expansion.
The nurse should add sterile water to the suction control chamber to achieve the
prescribed level. Fluctuation in the water seal is a normal finding indicating that the chest
tube is patent and the lung is re-expanding. 75 mL of bright red blood is concerning but
may be expected immediately post-insertion; continued monitoring is needed, but the
suction level needs to be corrected first. Autotransfusion (b) would require specific orders
and is not a priority. Manipulating blood in the tubing (c) is not appropriate. Increasing
wall suction (d) is contraindicated and could cause tissue damage.
DIF: Cognitive Level: Apply (Application)
TOP: Chest Tube Management - Suction Control
MSC: HESI RN Exit Exam
QUESTION 3
A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100
mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is
manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on
room air of 89%. Which action should the nurse take first?
,a. Elevate the foot of the bed.
b. Restrict the client's fluid.
c. Begin supplemental oxygen.
d. Prepare the client for hemodialysis.
CORRECT ANS: c. Begin supplemental oxygen.
Expert Rationale
The client is exhibiting signs of fluid overload and pulmonary edema, characterized by
hypertension, tachycardia, tachypnea, shortness of breath, edema, and hypoxemia (SpO2
89%). This is a life-threatening emergency following hemodialysis, likely due to fluid
volume excess or inadequate fluid removal during dialysis. The priority intervention is to
address the hypoxemia by beginning supplemental oxygen to improve oxygenation and
prevent further respiratory compromise. While other interventions such as diuretics or
repositioning may be necessary, oxygen administration is the immediate priority to
maintain adequate tissue oxygenation. Elevating the foot of the bed (a) would worsen the
condition. Restricting fluid (b) and preparing for dialysis (d) are important but secondary
to oxygen administration.
DIF: Cognitive Level: Apply (Application)
TOP: Renal Nursing - Hemodialysis Complications
MSC: HESI RN Exit Exam
QUESTION 4
A client with Addison's crisis is admitted for treatment with adrenal cortical
supplementation. Based on the client's admitting diagnosis, which findings require
immediate action by the nurse? (Select all that apply.)
a. Headache and tremors
b. Irregular heart rate
c. Skin hyperpigmentation
d. Postural hypotension
e. Pallor and diaphoresis
CORRECT ANS: a. Headache and tremors; b. Irregular heart rate; d. Postural hypotension;
e. Pallor and diaphoresis
Expert Rationale
Addison's crisis is a life-threatening condition caused by acute adrenal insufficiency. It is
characterized by severe hypotension, dehydration, hypoglycemia, and electrolyte
imbalances (hyponatremia and hyperkalemia). The manifestations include headache and
, tremors (a) (due to hypoglycemia), irregular heart rate (b) (due to hyperkalemia), postural
hypotension (d), and pallor and diaphoresis (e) (due to hypotension and shock). These
findings indicate that the client is in crisis and require immediate action, including
administration of IV corticosteroids, IV fluids, and glucose. Skin hyperpigmentation (c) is a
chronic sign of Addison's disease and is not an acute finding requiring immediate action.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Endocrine Nursing - Addison's Crisis
MSC: HESI RN Exit Exam
QUESTION 5
An older client is admitted with fluid volume deficit and dehydration. Which assessment
finding is the best indicator of hydration that the nurse should report to the healthcare
provider?
a. Urine specific gravity is 1.040
b. Systolic blood pressure decreases 10 points when standing.
c. The client denies being thirsty.
d. Skin tenting occurs when the client's forearm is pinched.
CORRECT ANS: d. Skin tenting occurs when the client's forearm is pinched.
Expert Rationale
Skin tenting (loss of skin turgor) is a classic sign of dehydration. When the skin is pinched
and fails to return to its normal position, it indicates a loss of interstitial fluid. This finding
is a reliable indicator of fluid volume deficit, especially in older adults. The forearm is a
more reliable site for assessing skin turgor in older adults than the sternum or back of the
hand, as skin elasticity is often decreased due to aging. Reporting skin tenting to the
healthcare provider provides objective data to support the diagnosis and guide fluid
replacement therapy. A urine specific gravity of 1.040 (a) indicates concentrated urine,
which can be a sign of dehydration, but skin tenting is a more direct indicator of
extracellular fluid loss. Orthostatic hypotension (b) is a sign of dehydration but can be
influenced by other factors. The client denying thirst (c) is not a reliable indicator, as older
adults often have a decreased thirst mechanism.
DIF: Cognitive Level: Apply (Application)
TOP: Fluid and Electrolyte Balance - Dehydration
MSC: HESI RN Exit Exam
