HESI EXIT EXAM COMPREHENSIVE
REVIEW QUESTIONS AND CORRECT
DETAILED ANSWERS
1. A nurse is caring for a client with a history of heart failure who suddenly develops dyspnea,
tachypnea, and cough with pink, frothy sputum. Which action should the nurse take first?
A. Check the client’s oxygen saturation levels
B. Administer the prescribed PRN dose of furosemide
C. Auscultate the client’s lung sounds
D. Position the client in high-Fowler’s position
Answer: D
Conceptual Explanation: High-Fowler’s position promotes lung expansion and facilitates
gas exchange, which is the immediate priority for a client in pulmonary edema.
2. A client is receiving magnesium sulfate for the treatment of preeclampsia. Which
assessment finding should the nurse report to the healthcare provider immediately?
A. Urinary output of 40 mL over the last 2 hours
B. Deep tendon reflexes of +1
C. Respiratory rate of 10 breaths per minute
D. Blood pressure of 150/96 mmHg
,Answer: C
Conceptual Explanation: Magnesium sulfate toxicity leads to respiratory depression (rate
<12) and loss of deep tendon reflexes; a respiratory rate of 10 is a critical sign of toxicity.
3. The nurse is reviewing the laboratory results for a client receiving heparin for a pulmonary
embolism. The aPTT is 110 seconds (control is 35 seconds). What is the priority action?
A. Continue the infusion as prescribed
B. Increase the infusion rate to reach a therapeutic level
C. Stop the heparin infusion and notify the provider
D. Prepare to administer vitamin K
Answer: C
Conceptual Explanation: A therapeutic aPTT is typically 1.5 to 2.5 times the control. An
aPTT of 110 is significantly high, indicating a risk for bleeding; the infusion must be
stopped immediately.
4. A client presents with a suspected diagnosis of autonomic dysreflexia. Which initial
intervention should the nurse perform?
A. Administer an antihypertensive medication
B. Lower the head of the bed to a flat position
C. Check for bladder distension or a kinked catheter
D. Assess the client’s skin for pressure injuries
, Answer: C
Conceptual Explanation: Autonomic dysreflexia is often triggered by a full bladder or
bowel; identifying and removing the stimulus is the priority, alongside elevating the head
of the bed.
5. A nurse is teaching a client who has been newly prescribed lithium for bipolar disorder.
Which statement by the client indicates an understanding of the teaching?
A. I need to drink 2 to 3 liters of fluid every day
B. I should limit my sodium intake to prevent toxicity
C. If I feel a cold coming on, I can take ibuprofen
D. I will stop the medication once my mood stabilizes
Answer: A
Conceptual Explanation: Adequate fluid intake (2-3 L/day) and consistent sodium intake
are required to maintain stable lithium levels and prevent toxicity.
6. Which task can the RN safely delegate to a licensed practical nurse (LPN)?
A. Teaching a new diabetic client how to inject insulin
B. Performing the initial assessment on a post-operative client
C. Administering oral medications to a stable client
D. Developing the plan of care for a client with heart failure
Answer: C
REVIEW QUESTIONS AND CORRECT
DETAILED ANSWERS
1. A nurse is caring for a client with a history of heart failure who suddenly develops dyspnea,
tachypnea, and cough with pink, frothy sputum. Which action should the nurse take first?
A. Check the client’s oxygen saturation levels
B. Administer the prescribed PRN dose of furosemide
C. Auscultate the client’s lung sounds
D. Position the client in high-Fowler’s position
Answer: D
Conceptual Explanation: High-Fowler’s position promotes lung expansion and facilitates
gas exchange, which is the immediate priority for a client in pulmonary edema.
2. A client is receiving magnesium sulfate for the treatment of preeclampsia. Which
assessment finding should the nurse report to the healthcare provider immediately?
A. Urinary output of 40 mL over the last 2 hours
B. Deep tendon reflexes of +1
C. Respiratory rate of 10 breaths per minute
D. Blood pressure of 150/96 mmHg
,Answer: C
Conceptual Explanation: Magnesium sulfate toxicity leads to respiratory depression (rate
<12) and loss of deep tendon reflexes; a respiratory rate of 10 is a critical sign of toxicity.
3. The nurse is reviewing the laboratory results for a client receiving heparin for a pulmonary
embolism. The aPTT is 110 seconds (control is 35 seconds). What is the priority action?
A. Continue the infusion as prescribed
B. Increase the infusion rate to reach a therapeutic level
C. Stop the heparin infusion and notify the provider
D. Prepare to administer vitamin K
Answer: C
Conceptual Explanation: A therapeutic aPTT is typically 1.5 to 2.5 times the control. An
aPTT of 110 is significantly high, indicating a risk for bleeding; the infusion must be
stopped immediately.
4. A client presents with a suspected diagnosis of autonomic dysreflexia. Which initial
intervention should the nurse perform?
A. Administer an antihypertensive medication
B. Lower the head of the bed to a flat position
C. Check for bladder distension or a kinked catheter
D. Assess the client’s skin for pressure injuries
, Answer: C
Conceptual Explanation: Autonomic dysreflexia is often triggered by a full bladder or
bowel; identifying and removing the stimulus is the priority, alongside elevating the head
of the bed.
5. A nurse is teaching a client who has been newly prescribed lithium for bipolar disorder.
Which statement by the client indicates an understanding of the teaching?
A. I need to drink 2 to 3 liters of fluid every day
B. I should limit my sodium intake to prevent toxicity
C. If I feel a cold coming on, I can take ibuprofen
D. I will stop the medication once my mood stabilizes
Answer: A
Conceptual Explanation: Adequate fluid intake (2-3 L/day) and consistent sodium intake
are required to maintain stable lithium levels and prevent toxicity.
6. Which task can the RN safely delegate to a licensed practical nurse (LPN)?
A. Teaching a new diabetic client how to inject insulin
B. Performing the initial assessment on a post-operative client
C. Administering oral medications to a stable client
D. Developing the plan of care for a client with heart failure
Answer: C
