HESI Exit V2 Exam with NGN Questions and Answers
(Verified by Expert)
1. The nurse assumes care of a postoperative adult client with type 2 diabetesmellitus
and learns that the client has a current blood glucose level of 720 mg/dL. When
assessing the client, what is the priority?
A. Assess for signs of fluid volume deficit
B. Observe wound drainage characteristics
C. Measure the level of acute pain
D. Determine when the client last ate
ANS: A. Assess for signs of fluid volume deficit
2. A male client tells the nurse that he is concerned that he may have a stomachulcer,
because he is experiencing heartburn and dull gnawing pain that is relieved when he
eats. Which is the best response by the nurse?
A. Encourage the client to obtain a complete physical exam, since thesesymptoms
are consistent with an ulcer
B. Assure the client that his symptoms may only reflect reflux, since ulcer painis not
relieved with food
C. Instruct the client that these mild symptoms can generally be controlledwith
changes in his diet
,D. Advise the client that he needs to seek immediate medical evaluation
and treatment of these symptoms
ANS: A. Encourage the client to obtain a completephysical exam, since these symptoms
are consistent with an ulcer
3. 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/hr IV. One hour after admission to the unit, the nursenotes 300mL 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 reportingthe findings 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 for placement of a central venous catheter
D. Increase the infusion rate of Lactated Ringer's solution
ANS: D. Increase theinfusion rate of Lactated Ringer's solution
4. A heparin infusion is prescribed for a client who weighs 220 pounds. After
administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the
heparin solution as 18 units/kg/hour. The available solution is He-parin Sodium 25,000
Units in 5% Dextrose Injection 250 mL. The nurse shouldprogram the infusion pump to
deliver how many mL/hour
,ANS -1st: calculate the weight = 220/2.2= 100kg
-Then calculate total dose in units = 18units x 100kg = 1800 units/hr
- 25000 units - in 250
, 1800 units ---in X ml
x = 1800 x 250/25000 =18 mL/hr
5. 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 emergencydepartment prior to
his transfer to the intensive care unit (ICU). The nurse notes that the suction control
chamber is bubbling at the -10cm H2O mark, which fluctuation in the water seal, and
over the past hour 75 mL of bright redblood 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
ANS: A. Add sterilewater to the suction control chamber
6. An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife
approaches the nurse and asks how she will know that her husband'sdeath is imminent
because their two adult children want to be there when he dies. Which is the best
response by the nurse?
A. Gather information regarding how long it will take for the children to arrive
B. Explain that the client will start to lose consciousness and the body sys-tems will
slow down
C. Reassure the spouse that the healthcare provider will notify when to call thechildren
(Verified by Expert)
1. The nurse assumes care of a postoperative adult client with type 2 diabetesmellitus
and learns that the client has a current blood glucose level of 720 mg/dL. When
assessing the client, what is the priority?
A. Assess for signs of fluid volume deficit
B. Observe wound drainage characteristics
C. Measure the level of acute pain
D. Determine when the client last ate
ANS: A. Assess for signs of fluid volume deficit
2. A male client tells the nurse that he is concerned that he may have a stomachulcer,
because he is experiencing heartburn and dull gnawing pain that is relieved when he
eats. Which is the best response by the nurse?
A. Encourage the client to obtain a complete physical exam, since thesesymptoms
are consistent with an ulcer
B. Assure the client that his symptoms may only reflect reflux, since ulcer painis not
relieved with food
C. Instruct the client that these mild symptoms can generally be controlledwith
changes in his diet
,D. Advise the client that he needs to seek immediate medical evaluation
and treatment of these symptoms
ANS: A. Encourage the client to obtain a completephysical exam, since these symptoms
are consistent with an ulcer
3. 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/hr IV. One hour after admission to the unit, the nursenotes 300mL 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 reportingthe findings 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 for placement of a central venous catheter
D. Increase the infusion rate of Lactated Ringer's solution
ANS: D. Increase theinfusion rate of Lactated Ringer's solution
4. A heparin infusion is prescribed for a client who weighs 220 pounds. After
administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the
heparin solution as 18 units/kg/hour. The available solution is He-parin Sodium 25,000
Units in 5% Dextrose Injection 250 mL. The nurse shouldprogram the infusion pump to
deliver how many mL/hour
,ANS -1st: calculate the weight = 220/2.2= 100kg
-Then calculate total dose in units = 18units x 100kg = 1800 units/hr
- 25000 units - in 250
, 1800 units ---in X ml
x = 1800 x 250/25000 =18 mL/hr
5. 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 emergencydepartment prior to
his transfer to the intensive care unit (ICU). The nurse notes that the suction control
chamber is bubbling at the -10cm H2O mark, which fluctuation in the water seal, and
over the past hour 75 mL of bright redblood 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
ANS: A. Add sterilewater to the suction control chamber
6. An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife
approaches the nurse and asks how she will know that her husband'sdeath is imminent
because their two adult children want to be there when he dies. Which is the best
response by the nurse?
A. Gather information regarding how long it will take for the children to arrive
B. Explain that the client will start to lose consciousness and the body sys-tems will
slow down
C. Reassure the spouse that the healthcare provider will notify when to call thechildren
