HESI RN 2024 EXIT EXAM QUESTIONS
AND ANSWERS
Whenzpreparingztozadministerzazprescribedzmedicationztozazhomelesszclientzatzazcom
munityzpsychiatriczclinic.zThezclientztellsztheznursezthatzthezusualzdosageztakenziszdiffer
entzfromzthezdoseztheznurseziszgiving.zWhichzactionzshouldztheznurseztake?z
A)zInformzthezclientzthatzhezmayzrefusezthezmedicationzandzdocumentzwhetherzorznotzt
hezclientztakeszit.z
B)zWithholdzthezmedicationzuntilzthezdosagezcanzbezconfirmed.z
C)zExplainztozthezclientzthatzthezdosagezhaszbeenzchanged.z
D)zTellzthezclientztoztakezthezmedicationzthenzverifyzthezdosagezatztheznextzhealthcarezt
eamzmeeting.z-zanswer--
B)zWithholdzthezmedicationzuntilzthezdosagezcanzbezconfirmed.
Thezchargeznurseziszmakingzassignmentszforzonezpracticalznursezandzthreezregisteredz
nurseszwhozarezcaringzforzneurologicallyzcompromisedzclients.zWhichzclientzwithzwhich
zchangezinzstatusziszbestztozassignztozthezPN?z
A)zSubduralzhematomazwhosezbloodzpressurezchangedzfromz150/80ztoz170/60.
B)zViralzmeningitiszwhoseztemperaturezchangezfromz101zSztoz102F.z
C)zDiabeticzketozacidosiszwhoziszGlasgowzcomazscalezscorezchangedzfromz10ztoz7.z
D)zMyxedema,zwhosezbloodzpressurezchangezfromz80/50ztoz70/40.z-zanswer--
B)zViralzmeningitiszwhoseztemperaturezchangezfromz101zSztoz102F.
Theznurseziszcaringzforzazclientzwithzpneumoniazwhoznowzdevelopszinitialzsignszofzsepti
czshockzandzmultizorganzfailure.zThezhealthcarezproviderzprescribeszazsepsiszprotocol.z
Whichzinterventionziszmostzimportantzforztheznurseztozincludezinzthezplanzofzcare?z
A)zMaintainzstrictzintakezandzoutput.z
B)zKeepzheadzofzbedzraisedz45°.z
C)zExcesszwarmthzofzextremities.z
D)zMonitorzbloodzglucosezlevel.z-zanswer--A)zMaintainzstrictzintakezandzoutput.
Andzadolescentzclientziszadmittedztozthezhospitalzbecausezofzwritingzazsuicideznoteztoza
zteacherzatzschool.zOnzthezsecondzdayzofzhospitalization, ztheznursezaskedzthezclientztoz
meetzwithztheztreatmentzteam.zAfterzthezteamzmeeting,zthezclientzleaveszinztearszandzg
oesztoztheirzroom.zWhichznursingzinterventionziszbest?z
A)zLetzthezclientzrestzquietlyzinztheirzroomzforzazwhile.z
B)zExplorezthezclientszgoalszandzdesirezforztreatment.z
C)zAskztheztreatmentzteamzaboutzthezclientszbehavior.z
D)zGoztozthezclientszroomzandzaskzwhatzhappened.z-zanswer--
D)zGoztozthezclientszroomzandzaskzwhatzhappened.
,Thezhealthcarezproviderzprescribeszdalteparinz200zunitszperzkilogramzsubcutaneouszo
ncezazdayzforzazclientzwhozweighsz154zpounds.zThezmedicationziszavailablezandz25,00
0zunitszperzmilliliterzvial.zHowzmanyzmilliliterszshouldztheznursezadminister?
z(Enterznumericalzvaluezonly.zIfzroundingziszrequired,zroundztoztheznearestz10th.)z-
zanswer--0.6
NGN:zThezclientziszaz49-year-
oldzmalezwhozreportszfluzlikezsymptomszincludingzfeverzandzchestzcongestionzforzfourzd
ays.zHezcameztozthezemergencyzdepartmentzlastznightzwhenzhezwaszhavingzmorezdiffic
ultyzbreathingzhezhaszazhistoryzofz1/2zpackzazdayzcigarettezsmokingzforz20zyears.zHezh
asznozsignificantzmedicalzorzsurgicalzhistory.z
Whichztwozorderszshouldztheznursezcompletezfirst?z
A)zSputumzculture.z
B)zStartzoxygenz3zLzperzminutezviaznasalzcannula.z
C)zPlacezthezclientzonzazcardiozrespiratoryzmonitor.z
D)zChestzx-ray.z
E)zAcetominophenz350zmgzPOzeveryzsixzhourszforztemperaturezcontrol.z
F)zRunz0.9%zsodiumzchloridezIVzinfusionzatz150zmLzperzhour.z
G)zStartzperipheralzIV.z
H)zNPO.z-zanswer--B)zStartzoxygenz3zLzperzminutezviaznasalzcannula.z
C)zPlacezthezclientzonzazcardiozrespiratoryzmonitor.
NGN:z0330:zplacezthezclientzonzazcardiozrespiratoryzmonitor,zNPO,zsputumzculture,zsta
rtzazperipheralzIVzinfusion,zstartzoxygenz3zLzperzminutezviaznasalzcannula,zbeginz0.9%z
sodiumzchloridezIVzinfusionzatz150zmLzperzhour,zacetaminophenz350zmgzPOzeveryzsixz
hourszforztemperature.
Tozstartzthezclientzonzoxygenzaszorderedzwhichzitemszshouldztheznursezcollectszfromzth
ezsupplyzroom?zSATAz
A)zhumidifierzbottle.z
B)Suctionzcanister.z
C)Sterilezwater.z
D)zNasalzcannula.z
E)zFlowzmeter.z
F)zLambszwool.z
G)zTape.z-zanswer--D)zNasalzcannula.z
E)zFlowzmeter.
NGN:zstates,zIzamzfeelingzextremelyzanxiouszrightznow.zThezclientzhaszdecreasedzbrea
thzsoundszinzthezleftzlowerzlow.zHiszmucuszmembraneszarezdry.zHezhaszazproductivezc
oughzwithzthick,zyellowzsecretions.zHiszcapillaryzrefillziszfourzseconds.zVitalzsigns,ztemp
eraturez100.2.zHeartzratez101zbpm,zrespiratoryzratez28zbreathszperzminute,zbloodzpres
surez145/89,zoxygenzsaturationz90%zonzroomzair.
(forzeachzbodyzsystemzclickztozspecifyzthezassessmentzfindingszthatzindicateszhypoxia)
Cardiovascular:zheartzratez100zbpm,zcapillaryzrefillzforzseconds,zbloodzpressurez145/8
9.
Neurological:zanxious,zawakezandzalert,zrestless.
, Respiratory:zoxygenzsaturationz90%zonzroomzair,zrespiratoryzratez28zbpm,zproductivez
cough.z-zanswer--Cardiovascular:zcapillaryzrefillzforzseconds,zbloodzpressurez145/89.
Neurological:zanxious,zrestless.
Respiratory:zoxygenzsaturationz90%zonzroomzair,zrespiratoryzratez28zbpm.
NGN:zThezclientziszaz49-year-
oldzmalezwhozreportszfluzlikezsymptomszincludingzfeverzandzchestzcongestionzforzfourzd
ays.zHezcameztozthezemergencyzdepartmentzlastznightzwhenzhezwaszhavingzmorezdiffic
ultyzbreathingzhezhaszazhistoryzofz1/2zpackzazdayzcigarettezsmokingzforz20zyears.zHezh
asznozsignificantzmedicalzorzsurgicalzhistory.z
Theznursezshouldzplacezthezclientzinzaz_______________zpositionztozpromotez______
_______.z-zanswer--Semi-Fowlerz,zlungzexpansion.
NGN:zOrders:z0330:zplacezthezclientzonzazcardiozrespiratoryzmonitor,zNPO,zsputumzcul
ture,zstartzazPIV,zstartzoxygenz3Lzviaznasalzcannula,znormalzsalinez150zMLzperzhour,za
cetaminophenz350mgzPOzeveryzsixzhourszforztempzgreaterzthanz101F,zchestzx-ray.
0500:zOxygenz8Lviazsimplezfacemask,ztitrateztozkeepzoxygenzsaturationzgreaterzthanz9
4%.
(markzwhetherzthezstatementszbyztheznewzgradznursezindicatezunderstandingzorznozun
derstandingzofzthezusezofzfacemaskzinzthezcarezofzthiszclient)
-Izshouldzcleanzthezfacemaskzoncezperzshift.
-Thezclientzshouldztakezaz1ztoz2zminutezbreakzfromzthezfacemaskzeachzhour.
-Izshouldzputzgauzezunderzthezelasticzstrapszoverzthezears.
-
Izcanzadjustzthezoxygenzlevelzonzthezflowzmeterztozkeepzthezclientszoxygenzsaturationzg
reaterzthanz94%.
-Thezmaskzshouldzcoverzonlyzthezmouthzandzleaveztheznosezopenzforzexpiration.
-Izshouldzplacezthezmaskzfirstzoverztheznosezandzthenzcoverzthezmouth.z-zanswer---
Izshouldzcleanzthezfacemaskzoncezperzshift.z(UNDERSTANDING)
-
Thezclientzshouldztakezaz1ztoz2zminutezbreakzfromzthezfacemaskzeachzhour.z(NOTzUN
DERSTANDING)
-
Izshouldzputzgauzezunderzthezelasticzstrapszoverzthezears.z(NOTzUNDERSTANDINGz?
???)
-
Izcanzadjustzthezoxygenzlevelzonzthezflowzmeterztozkeepzthezclientszoxygenzsaturationzg
reaterzthanz94%.z(UNDERSTANDING)
-
Thezmaskzshouldzcoverzonlyzthezmouthzandzleaveztheznosezopenzforzexpiration.z(NOTz
UNDERSTANDING)
-
Izshouldzplacezthezmaskzfirstzoverztheznosezandzthenzcoverzthezmouth.z(UNDERSTAN
DING)
NGN:zNurseszNotes:z0400,zthezclientziszawakezandzalertzbutzrestless.zHezstateszIzamzfe
elingzextremelyzanxiouszrightznow.zThezclientzhaszdecreasedzbreathzsoundszinzthezleftzl
AND ANSWERS
Whenzpreparingztozadministerzazprescribedzmedicationztozazhomelesszclientzatzazcom
munityzpsychiatriczclinic.zThezclientztellsztheznursezthatzthezusualzdosageztakenziszdiffer
entzfromzthezdoseztheznurseziszgiving.zWhichzactionzshouldztheznurseztake?z
A)zInformzthezclientzthatzhezmayzrefusezthezmedicationzandzdocumentzwhetherzorznotzt
hezclientztakeszit.z
B)zWithholdzthezmedicationzuntilzthezdosagezcanzbezconfirmed.z
C)zExplainztozthezclientzthatzthezdosagezhaszbeenzchanged.z
D)zTellzthezclientztoztakezthezmedicationzthenzverifyzthezdosagezatztheznextzhealthcarezt
eamzmeeting.z-zanswer--
B)zWithholdzthezmedicationzuntilzthezdosagezcanzbezconfirmed.
Thezchargeznurseziszmakingzassignmentszforzonezpracticalznursezandzthreezregisteredz
nurseszwhozarezcaringzforzneurologicallyzcompromisedzclients.zWhichzclientzwithzwhich
zchangezinzstatusziszbestztozassignztozthezPN?z
A)zSubduralzhematomazwhosezbloodzpressurezchangedzfromz150/80ztoz170/60.
B)zViralzmeningitiszwhoseztemperaturezchangezfromz101zSztoz102F.z
C)zDiabeticzketozacidosiszwhoziszGlasgowzcomazscalezscorezchangedzfromz10ztoz7.z
D)zMyxedema,zwhosezbloodzpressurezchangezfromz80/50ztoz70/40.z-zanswer--
B)zViralzmeningitiszwhoseztemperaturezchangezfromz101zSztoz102F.
Theznurseziszcaringzforzazclientzwithzpneumoniazwhoznowzdevelopszinitialzsignszofzsepti
czshockzandzmultizorganzfailure.zThezhealthcarezproviderzprescribeszazsepsiszprotocol.z
Whichzinterventionziszmostzimportantzforztheznurseztozincludezinzthezplanzofzcare?z
A)zMaintainzstrictzintakezandzoutput.z
B)zKeepzheadzofzbedzraisedz45°.z
C)zExcesszwarmthzofzextremities.z
D)zMonitorzbloodzglucosezlevel.z-zanswer--A)zMaintainzstrictzintakezandzoutput.
Andzadolescentzclientziszadmittedztozthezhospitalzbecausezofzwritingzazsuicideznoteztoza
zteacherzatzschool.zOnzthezsecondzdayzofzhospitalization, ztheznursezaskedzthezclientztoz
meetzwithztheztreatmentzteam.zAfterzthezteamzmeeting,zthezclientzleaveszinztearszandzg
oesztoztheirzroom.zWhichznursingzinterventionziszbest?z
A)zLetzthezclientzrestzquietlyzinztheirzroomzforzazwhile.z
B)zExplorezthezclientszgoalszandzdesirezforztreatment.z
C)zAskztheztreatmentzteamzaboutzthezclientszbehavior.z
D)zGoztozthezclientszroomzandzaskzwhatzhappened.z-zanswer--
D)zGoztozthezclientszroomzandzaskzwhatzhappened.
,Thezhealthcarezproviderzprescribeszdalteparinz200zunitszperzkilogramzsubcutaneouszo
ncezazdayzforzazclientzwhozweighsz154zpounds.zThezmedicationziszavailablezandz25,00
0zunitszperzmilliliterzvial.zHowzmanyzmilliliterszshouldztheznursezadminister?
z(Enterznumericalzvaluezonly.zIfzroundingziszrequired,zroundztoztheznearestz10th.)z-
zanswer--0.6
NGN:zThezclientziszaz49-year-
oldzmalezwhozreportszfluzlikezsymptomszincludingzfeverzandzchestzcongestionzforzfourzd
ays.zHezcameztozthezemergencyzdepartmentzlastznightzwhenzhezwaszhavingzmorezdiffic
ultyzbreathingzhezhaszazhistoryzofz1/2zpackzazdayzcigarettezsmokingzforz20zyears.zHezh
asznozsignificantzmedicalzorzsurgicalzhistory.z
Whichztwozorderszshouldztheznursezcompletezfirst?z
A)zSputumzculture.z
B)zStartzoxygenz3zLzperzminutezviaznasalzcannula.z
C)zPlacezthezclientzonzazcardiozrespiratoryzmonitor.z
D)zChestzx-ray.z
E)zAcetominophenz350zmgzPOzeveryzsixzhourszforztemperaturezcontrol.z
F)zRunz0.9%zsodiumzchloridezIVzinfusionzatz150zmLzperzhour.z
G)zStartzperipheralzIV.z
H)zNPO.z-zanswer--B)zStartzoxygenz3zLzperzminutezviaznasalzcannula.z
C)zPlacezthezclientzonzazcardiozrespiratoryzmonitor.
NGN:z0330:zplacezthezclientzonzazcardiozrespiratoryzmonitor,zNPO,zsputumzculture,zsta
rtzazperipheralzIVzinfusion,zstartzoxygenz3zLzperzminutezviaznasalzcannula,zbeginz0.9%z
sodiumzchloridezIVzinfusionzatz150zmLzperzhour,zacetaminophenz350zmgzPOzeveryzsixz
hourszforztemperature.
Tozstartzthezclientzonzoxygenzaszorderedzwhichzitemszshouldztheznursezcollectszfromzth
ezsupplyzroom?zSATAz
A)zhumidifierzbottle.z
B)Suctionzcanister.z
C)Sterilezwater.z
D)zNasalzcannula.z
E)zFlowzmeter.z
F)zLambszwool.z
G)zTape.z-zanswer--D)zNasalzcannula.z
E)zFlowzmeter.
NGN:zstates,zIzamzfeelingzextremelyzanxiouszrightznow.zThezclientzhaszdecreasedzbrea
thzsoundszinzthezleftzlowerzlow.zHiszmucuszmembraneszarezdry.zHezhaszazproductivezc
oughzwithzthick,zyellowzsecretions.zHiszcapillaryzrefillziszfourzseconds.zVitalzsigns,ztemp
eraturez100.2.zHeartzratez101zbpm,zrespiratoryzratez28zbreathszperzminute,zbloodzpres
surez145/89,zoxygenzsaturationz90%zonzroomzair.
(forzeachzbodyzsystemzclickztozspecifyzthezassessmentzfindingszthatzindicateszhypoxia)
Cardiovascular:zheartzratez100zbpm,zcapillaryzrefillzforzseconds,zbloodzpressurez145/8
9.
Neurological:zanxious,zawakezandzalert,zrestless.
, Respiratory:zoxygenzsaturationz90%zonzroomzair,zrespiratoryzratez28zbpm,zproductivez
cough.z-zanswer--Cardiovascular:zcapillaryzrefillzforzseconds,zbloodzpressurez145/89.
Neurological:zanxious,zrestless.
Respiratory:zoxygenzsaturationz90%zonzroomzair,zrespiratoryzratez28zbpm.
NGN:zThezclientziszaz49-year-
oldzmalezwhozreportszfluzlikezsymptomszincludingzfeverzandzchestzcongestionzforzfourzd
ays.zHezcameztozthezemergencyzdepartmentzlastznightzwhenzhezwaszhavingzmorezdiffic
ultyzbreathingzhezhaszazhistoryzofz1/2zpackzazdayzcigarettezsmokingzforz20zyears.zHezh
asznozsignificantzmedicalzorzsurgicalzhistory.z
Theznursezshouldzplacezthezclientzinzaz_______________zpositionztozpromotez______
_______.z-zanswer--Semi-Fowlerz,zlungzexpansion.
NGN:zOrders:z0330:zplacezthezclientzonzazcardiozrespiratoryzmonitor,zNPO,zsputumzcul
ture,zstartzazPIV,zstartzoxygenz3Lzviaznasalzcannula,znormalzsalinez150zMLzperzhour,za
cetaminophenz350mgzPOzeveryzsixzhourszforztempzgreaterzthanz101F,zchestzx-ray.
0500:zOxygenz8Lviazsimplezfacemask,ztitrateztozkeepzoxygenzsaturationzgreaterzthanz9
4%.
(markzwhetherzthezstatementszbyztheznewzgradznursezindicatezunderstandingzorznozun
derstandingzofzthezusezofzfacemaskzinzthezcarezofzthiszclient)
-Izshouldzcleanzthezfacemaskzoncezperzshift.
-Thezclientzshouldztakezaz1ztoz2zminutezbreakzfromzthezfacemaskzeachzhour.
-Izshouldzputzgauzezunderzthezelasticzstrapszoverzthezears.
-
Izcanzadjustzthezoxygenzlevelzonzthezflowzmeterztozkeepzthezclientszoxygenzsaturationzg
reaterzthanz94%.
-Thezmaskzshouldzcoverzonlyzthezmouthzandzleaveztheznosezopenzforzexpiration.
-Izshouldzplacezthezmaskzfirstzoverztheznosezandzthenzcoverzthezmouth.z-zanswer---
Izshouldzcleanzthezfacemaskzoncezperzshift.z(UNDERSTANDING)
-
Thezclientzshouldztakezaz1ztoz2zminutezbreakzfromzthezfacemaskzeachzhour.z(NOTzUN
DERSTANDING)
-
Izshouldzputzgauzezunderzthezelasticzstrapszoverzthezears.z(NOTzUNDERSTANDINGz?
???)
-
Izcanzadjustzthezoxygenzlevelzonzthezflowzmeterztozkeepzthezclientszoxygenzsaturationzg
reaterzthanz94%.z(UNDERSTANDING)
-
Thezmaskzshouldzcoverzonlyzthezmouthzandzleaveztheznosezopenzforzexpiration.z(NOTz
UNDERSTANDING)
-
Izshouldzplacezthezmaskzfirstzoverztheznosezandzthenzcoverzthezmouth.z(UNDERSTAN
DING)
NGN:zNurseszNotes:z0400,zthezclientziszawakezandzalertzbutzrestless.zHezstateszIzamzfe
elingzextremelyzanxiouszrightznow.zThezclientzhaszdecreasedzbreathzsoundszinzthezleftzl
