EXIT HESI (BSN 366- V3)
COMPREHENSIVE EXAM QUESTIONS
AND VERIFIED ANSWERS | 100%
CORRECT | GRADE A+
1. A nurse is caring for a client with Diabetic Ketoacidosis (DKA). Which of the following
laboratory findings should the nurse expect?
A. pH 7.50, PaCO2 40, HCO3 30
B. pH 7.48, PaCO2 30, HCO3 22
C. pH 7.35, PaCO2 48, HCO3 28
D. pH 7.32, PaCO2 36, HCO3 14
Answer: D
Conceptual Explanation: DKA is characterized by metabolic acidosis. A pH below 7.35 and
a low bicarbonate level (HCO3 < 18) are hallmark signs.
2. A client is receiving Magnesium Sulfate for preeclampsia. The nurse notes absent deep
tendon reflexes and a respiratory rate of 10 breaths/min. What is the priority action?
A. Decrease the infusion rate by half
,B. Prepare for immediate delivery
C. Administer oxygen via non-rebreather mask
D. Stop the infusion and notify the provider
Answer: D
Conceptual Explanation: Absent reflexes and respiratory depression are signs of
magnesium toxicity. The infusion must be stopped immediately to prevent cardiac arrest.
3. The nurse is assessing a child with suspected epiglottitis. Which action is contraindicated?
A. Assessing the child’s oxygen saturation
B. Preparing for endotracheal intubation
C. Placing the child in a tripod position
D. Obtaining a throat culture with a sterile swab
Answer: D
Conceptual Explanation: Inserting a swab into the throat of a child with epiglottitis can
cause complete airway obstruction due to laryngospasm.
4. A client diagnosed with Schizophrenia is experiencing auditory hallucinations. What is the
most therapeutic nursing response?
A. ‘Why do you think the voices are talking to you right now?’
B. ‘I do not hear the voices, but I understand they are real to you.’
, C. ‘The voices are not real; you should try to ignore them.’
D. ‘What are the voices telling you to do?’
Answer: B
Conceptual Explanation: The nurse should acknowledge the client’s experience without
validating the hallucination as reality, providing a sense of safety and reality orientation.
5. A client taking Digoxin for heart failure reports blurred vision and seeing yellow-green
halos. The nurse should first:
A. Check the client’s serum potassium level
B. Administer the next scheduled dose of Digoxin
C. Assess the client’s apical pulse for one full minute
D. Request an order for a Digoxin immune fab
Answer: C
Conceptual Explanation: Visual disturbances are classic signs of Digoxin toxicity. The
nurse must first assess the pulse to determine the immediate physiological impact before
checking labs.
6. The nurse is assigned to four clients. Which client should be assessed first?
A. A client with pneumonia who has a pulse oximetry of 92% on 2L NC
B. A client with a chest tube that has 150 mL of bright red drainage in the last hour
C. A client post-cholecystectomy reporting 6/10 pain
COMPREHENSIVE EXAM QUESTIONS
AND VERIFIED ANSWERS | 100%
CORRECT | GRADE A+
1. A nurse is caring for a client with Diabetic Ketoacidosis (DKA). Which of the following
laboratory findings should the nurse expect?
A. pH 7.50, PaCO2 40, HCO3 30
B. pH 7.48, PaCO2 30, HCO3 22
C. pH 7.35, PaCO2 48, HCO3 28
D. pH 7.32, PaCO2 36, HCO3 14
Answer: D
Conceptual Explanation: DKA is characterized by metabolic acidosis. A pH below 7.35 and
a low bicarbonate level (HCO3 < 18) are hallmark signs.
2. A client is receiving Magnesium Sulfate for preeclampsia. The nurse notes absent deep
tendon reflexes and a respiratory rate of 10 breaths/min. What is the priority action?
A. Decrease the infusion rate by half
,B. Prepare for immediate delivery
C. Administer oxygen via non-rebreather mask
D. Stop the infusion and notify the provider
Answer: D
Conceptual Explanation: Absent reflexes and respiratory depression are signs of
magnesium toxicity. The infusion must be stopped immediately to prevent cardiac arrest.
3. The nurse is assessing a child with suspected epiglottitis. Which action is contraindicated?
A. Assessing the child’s oxygen saturation
B. Preparing for endotracheal intubation
C. Placing the child in a tripod position
D. Obtaining a throat culture with a sterile swab
Answer: D
Conceptual Explanation: Inserting a swab into the throat of a child with epiglottitis can
cause complete airway obstruction due to laryngospasm.
4. A client diagnosed with Schizophrenia is experiencing auditory hallucinations. What is the
most therapeutic nursing response?
A. ‘Why do you think the voices are talking to you right now?’
B. ‘I do not hear the voices, but I understand they are real to you.’
, C. ‘The voices are not real; you should try to ignore them.’
D. ‘What are the voices telling you to do?’
Answer: B
Conceptual Explanation: The nurse should acknowledge the client’s experience without
validating the hallucination as reality, providing a sense of safety and reality orientation.
5. A client taking Digoxin for heart failure reports blurred vision and seeing yellow-green
halos. The nurse should first:
A. Check the client’s serum potassium level
B. Administer the next scheduled dose of Digoxin
C. Assess the client’s apical pulse for one full minute
D. Request an order for a Digoxin immune fab
Answer: C
Conceptual Explanation: Visual disturbances are classic signs of Digoxin toxicity. The
nurse must first assess the pulse to determine the immediate physiological impact before
checking labs.
6. The nurse is assigned to four clients. Which client should be assessed first?
A. A client with pneumonia who has a pulse oximetry of 92% on 2L NC
B. A client with a chest tube that has 150 mL of bright red drainage in the last hour
C. A client post-cholecystectomy reporting 6/10 pain
