PN HESI EXIT V2 – EXAMINATION 300 COMPLETE
QUESTIONS AND ANSWERS|2026 UPDATE|100%
CORRECT POST UNIVERSITY.
1. A client with heart failure is prescribed furosemide (Lasix) and digoxin (Lanoxin).
The client reports nausea and blurred vision. What action should the nurse take
first?
A) Administer an anti-emetic.
B) Check the client's apical pulse.
C) Hold the next dose of furosemide.
D) Encourage oral fluids.
Correct Answer: B) Check the client's apical pulse.
Rationale: Nausea and blurred vision are classic signs of digoxin toxicity. The nurse
must assess the apical pulse first; if bradycardic (< 60 bpm), the drug should be
held. Digoxin toxicity is a medical emergency that can lead to fatal dysrhythmias.
---
2. A postpartum client asks why her newborn is receiving vitamin K
(AquaMEPHYTON). What is the best response by the nurse?
A) "It prevents your baby from bleeding too much."
B) "It helps your baby's liver mature faster."
,C) "It boosts your baby's immune system."
D) "It helps your baby sleep better."
Correct Answer: A) "It prevents your baby from bleeding too much."
Rationale: Newborns have sterile guts and lack the bacteria necessary to
synthesize vitamin K, which is required for clotting factors (II, VII, IX, X). Vitamin K
is given prophylactically to prevent Hemorrhagic Disease of the Newborn.
---
3. A client with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 88%. The nurse administers oxygen at 2 L/min via nasal cannula.
What is the priority nursing assessment?
A) Monitor for increased sputum production.
B) Monitor the client's respiratory rate and effort.
C) Monitor for a decrease in oxygen saturation.
D) Monitor for a change in level of consciousness.
Correct Answer: D) Monitor for a change in level of consciousness.
Rationale: COPD clients are chronic CO2 retainers and rely on a hypoxic drive to
breathe. Administering too much oxygen can suppress this drive, leading to CO2
narcosis. A decreasing level of consciousness (LOC) is the earliest sign of CO2
retention and impending respiratory failure.
---
4. A client is 1 day post-total hip replacement. Which finding requires immediate
action by the nurse?
,A) Pain of 4 on a 0-10 scale.
B) Scant serosanguineous drainage on the dressing.
C) Shortness of breath and chest pain.
D) Constipation for 2 days.
Correct Answer: C) Shortness of breath and chest pain.
Rationale: Post-operative hip replacement clients are at high risk for a Pulmonary
Embolism (PE). Shortness of breath, pleuritic chest pain, and tachycardia are
hallmark signs of a PE and require immediate emergency intervention.
---
5. A client with schizophrenia is experiencing auditory hallucinations telling him to
"jump off the bridge." What is the most appropriate response by the nurse?
A) "I don't hear those voices, but I know you do."
B) "You must ignore those voices right now."
C) "God wouldn't tell you to do that."
D) "Let's go to your room to rest."
Correct Answer: A) "I don't hear those voices, but I know you do."
Rationale: The nurse should acknowledge the hallucination without reinforcing it
as reality. Option A validates the client's experience while establishing a reality
base. The nurse should never argue, rationalize, or tell the client to ignore the
voices. Safety is the priority.
---
, 6. A nurse is caring for a client with a nasogastric (NG) tube set to low intermittent
suction. Which finding indicates a potential complication?
A) Gastric output of 100 mL in 4 hours.
B) Dark brown drainage.
C) Abdominal rigidity and pain.
D) The client complains of a sore throat.
Correct Answer: C) Abdominal rigidity and pain.
Rationale: Abdominal rigidity, severe pain, and distension indicate peritoneal
irritation, which could be a sign of a perforated ulcer or misplaced NG tube. This is
an emergency. Sore throat and dark brown drainage are expected findings.
---
7. A client with type 1 diabetes is receiving 10 units of NPH insulin before
breakfast. At 3:00 PM, the nurse finds the client diaphoretic and trembling. What
should the nurse do first?
A) Give 50 mL of 50% Dextrose IV push.
B) Administer glucagon subcutaneously.
C) Give 4 oz of orange juice.
D) Check the client's blood glucose level.
Correct Answer: D) Check the client's blood glucose level.
Rationale: The client is showing signs of hypoglycemia. Although the nurse
suspects low blood sugar, the first action is to assess the blood glucose level to
confirm the diagnosis and determine the severity before implementing treatment.
QUESTIONS AND ANSWERS|2026 UPDATE|100%
CORRECT POST UNIVERSITY.
1. A client with heart failure is prescribed furosemide (Lasix) and digoxin (Lanoxin).
The client reports nausea and blurred vision. What action should the nurse take
first?
A) Administer an anti-emetic.
B) Check the client's apical pulse.
C) Hold the next dose of furosemide.
D) Encourage oral fluids.
Correct Answer: B) Check the client's apical pulse.
Rationale: Nausea and blurred vision are classic signs of digoxin toxicity. The nurse
must assess the apical pulse first; if bradycardic (< 60 bpm), the drug should be
held. Digoxin toxicity is a medical emergency that can lead to fatal dysrhythmias.
---
2. A postpartum client asks why her newborn is receiving vitamin K
(AquaMEPHYTON). What is the best response by the nurse?
A) "It prevents your baby from bleeding too much."
B) "It helps your baby's liver mature faster."
,C) "It boosts your baby's immune system."
D) "It helps your baby sleep better."
Correct Answer: A) "It prevents your baby from bleeding too much."
Rationale: Newborns have sterile guts and lack the bacteria necessary to
synthesize vitamin K, which is required for clotting factors (II, VII, IX, X). Vitamin K
is given prophylactically to prevent Hemorrhagic Disease of the Newborn.
---
3. A client with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 88%. The nurse administers oxygen at 2 L/min via nasal cannula.
What is the priority nursing assessment?
A) Monitor for increased sputum production.
B) Monitor the client's respiratory rate and effort.
C) Monitor for a decrease in oxygen saturation.
D) Monitor for a change in level of consciousness.
Correct Answer: D) Monitor for a change in level of consciousness.
Rationale: COPD clients are chronic CO2 retainers and rely on a hypoxic drive to
breathe. Administering too much oxygen can suppress this drive, leading to CO2
narcosis. A decreasing level of consciousness (LOC) is the earliest sign of CO2
retention and impending respiratory failure.
---
4. A client is 1 day post-total hip replacement. Which finding requires immediate
action by the nurse?
,A) Pain of 4 on a 0-10 scale.
B) Scant serosanguineous drainage on the dressing.
C) Shortness of breath and chest pain.
D) Constipation for 2 days.
Correct Answer: C) Shortness of breath and chest pain.
Rationale: Post-operative hip replacement clients are at high risk for a Pulmonary
Embolism (PE). Shortness of breath, pleuritic chest pain, and tachycardia are
hallmark signs of a PE and require immediate emergency intervention.
---
5. A client with schizophrenia is experiencing auditory hallucinations telling him to
"jump off the bridge." What is the most appropriate response by the nurse?
A) "I don't hear those voices, but I know you do."
B) "You must ignore those voices right now."
C) "God wouldn't tell you to do that."
D) "Let's go to your room to rest."
Correct Answer: A) "I don't hear those voices, but I know you do."
Rationale: The nurse should acknowledge the hallucination without reinforcing it
as reality. Option A validates the client's experience while establishing a reality
base. The nurse should never argue, rationalize, or tell the client to ignore the
voices. Safety is the priority.
---
, 6. A nurse is caring for a client with a nasogastric (NG) tube set to low intermittent
suction. Which finding indicates a potential complication?
A) Gastric output of 100 mL in 4 hours.
B) Dark brown drainage.
C) Abdominal rigidity and pain.
D) The client complains of a sore throat.
Correct Answer: C) Abdominal rigidity and pain.
Rationale: Abdominal rigidity, severe pain, and distension indicate peritoneal
irritation, which could be a sign of a perforated ulcer or misplaced NG tube. This is
an emergency. Sore throat and dark brown drainage are expected findings.
---
7. A client with type 1 diabetes is receiving 10 units of NPH insulin before
breakfast. At 3:00 PM, the nurse finds the client diaphoretic and trembling. What
should the nurse do first?
A) Give 50 mL of 50% Dextrose IV push.
B) Administer glucagon subcutaneously.
C) Give 4 oz of orange juice.
D) Check the client's blood glucose level.
Correct Answer: D) Check the client's blood glucose level.
Rationale: The client is showing signs of hypoglycemia. Although the nurse
suspects low blood sugar, the first action is to assess the blood glucose level to
confirm the diagnosis and determine the severity before implementing treatment.
