Questions With Complete Solutions with
Rationales
,2025 BRAND NEW HESI EXIT VERSION 3 Exam
Questions With Complete Solutions with
Rationales
1. A nurse is caring for a client who has a prescription for warfarin.
Which of the following instructions should the nurse include in the
teaching about the medication?
A. "You should avoid foods high in vitamin K, such as spinach and kale."
B. "You should increase your intake of foods that are high in vitamin C."
C. "It’s safe to take over-the-counter aspirin while on warfarin."
D. "The medication should be taken with food to prevent stomach upset."
Answer: A. "You should avoid foods high in vitamin K, such as spinach and
kale."
Rationale: Warfarin is an anticoagulant that works by inhibiting vitamin K-
dependent clotting factors. Foods high in vitamin K, such as leafy greens, can
reduce the effectiveness of warfarin. Vitamin C does not significantly affect
warfarin therapy, and aspirin should not be taken with warfarin unless
prescribed by the healthcare provider. Taking warfarin with food may help
prevent stomach upset, but it’s not the primary teaching focus.
2. A nurse is caring for a client with diabetes mellitus who is
experiencing a blood glucose level of 48 mg/dL. Which of the
following actions should the nurse take first?
A. Administer 1 mg of glucagon intramuscularly.
B. Provide the client with a glass of orange juice.
C. Give the client an insulin injection.
D. Call the healthcare provider for orders.
Answer: B. Provide the client with a glass of orange juice.
Rationale: A blood glucose level of 48 mg/dL indicates hypoglycemia. The
first action should be to provide a fast-acting carbohydrate like orange juice
to raise blood glucose. Administering glucagon is an option for severe
hypoglycemia if the client is unable to swallow. Insulin would further lower
the blood glucose and is not indicated for hypoglycemia. Calling the
healthcare provider is important, but the immediate need is to treat the
hypoglycemia.
, 2025 BRAND NEW HESI EXIT VERSION 3 Exam
Questions With Complete Solutions with
Rationales
3. A nurse is caring for a client who is 36 weeks pregnant and has
preeclampsia. Which of the following findings is most concerning?
A. A blood pressure reading of 160/100 mm Hg.
B. A positive urine dipstick for protein.
C. Weight gain of 2 pounds in 1 week.
D. Mild edema in the lower extremities.
Answer: A. A blood pressure reading of 160/100 mm Hg.
Rationale: Preeclampsia is characterized by high blood pressure and
proteinuria. A blood pressure reading of 160/100 mm Hg is concerning and
suggests worsening preeclampsia, which could lead to complications like
eclampsia or stroke. Proteinuria and mild edema are common in
preeclampsia, but the elevated blood pressure is the most urgent concern.
4. A nurse is caring for a client who has been prescribed lisinopril
for hypertension. Which of the following assessments is most
important to monitor during the initial phase of treatment?
A. Heart rate
B. Blood pressure
C. Respiratory rate
D. Blood glucose
Answer: B. Blood pressure
Rationale: Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor
used to treat hypertension. During the initial phase of treatment, it is
essential to monitor blood pressure to assess the effectiveness of the
medication and ensure it is not lowering the blood pressure too much.
Monitoring heart rate, respiratory rate, and blood glucose is important, but
blood pressure is the most critical during the initiation of lisinopril therapy.
5. A nurse is providing discharge teaching for a client who is
prescribed a new inhaler. Which of the following statements by the
client indicates that additional teaching is needed?
A. "I will inhale slowly and deeply while pressing the canister of the inhaler."
B. "I should hold my breath for 10 seconds after inhaling the medication."