HESI RN Exit V2 * Questions and
Answers
Ay12-year-
oldyclientywhoyhadyanyappendectomyytwoydaysyagoyisyreceivingy0.9%ynormalysalineyaty50
mL/hr.yTheyclient'syurineyspecificygravityyisy1.035.yWhichyactionyshouldytheynurseyimpleme
nt?y
A.yAssessybowelysoundsyinyallyquadrants
B.yEncourageypopsiclesyandyfluidsyofychoice
C.yEvaluateyposturalybloodypressureymeasurements
D.yObtainyayspecimenyforyurinalysisy-yCORRECTyyANSWER-
B.yEncourageypopsiclesyandyfluidsyofychoice
Ay3-year-
oldyboyywasysuccessfullyytoiletytrainedypriorytoyhisyadmissionytoytheyhospitalyforyinjuriesysu
stainedyfromyayfall.yHisyparentsyareyveryyconcernedythatytheychildyhasyregressedyinyhisytoil
etingybehaviors.yWhichyinformationyshouldytheynurseyprovideytoytheyparents?
A.yDiaperingywillybeyprovidedysinceyhospitalizationyisystressfulytoypreschoolers
B.yChildrenyusuallyyresumeytheirytoiletingybehaviorsywhenytheyyleaveytheyhospital
C.yAypottyychairyshouldybeybroughtyfromyhomeysoyheycanymaintainyhisytoiletingyskills
D.yAyretrainingyprogramywillyneedytoybeyinitiatedywhenytheychildyreturnsyhomey-
yCORRECTyyANSWER-
B.yChildrenyusuallyyresumeytheirytoiletingybehaviorsywhenytheyyleaveytheyhospital
Ay3-year-
oldyboyywithyaycongenitalyheartydefectyisybroughtytoytheyclinicybyyhisymotherybecauseyheyh
asyayfeveryandyanyearache.yDuringytheyassessment,ytheymotheryasksytheynurseywhyyheryc
hildyisyatythey5thypercentileyforyweightyandyheightyforyhisyage.yWhichyresponseyisybestyforyt
heynurseytoyprovide?
A.y"Doesyyourychildyseemymentallyyslowerythanyhisypeersyalso?"
B.y"Haven'tyyouybeenyfeedingyhimyaccordingytoyrecommendedydailyyallowancesyforychildr
en?"
C.y"Hisysmallerysizeyisyprobablyydueytoytheyheartydisease"
D.y"Youyshouldynotyworryyaboutytheygrowthytables.yTheyyareyonlyyaveragesyforychildren."y-
yCORRECTyyANSWER-C.y"Hisysmallerysizeyisyprobablyydueytoytheyheartydisease"
Ay41-
weekygestationyprimigravidaywomanyisyadmittedytoylaboryandydeliveryyforyinductionyofylabo
r.yWhichyfindingyshouldytheynurseyreportytoytheyhealthcareyproviderybeforeyinitiatingytheyinf
usionyofyoxytocin?
A.yRegularycontractionsyoccurringyeveryy10yminutes
,B.ySterileyvaginalyexamyrevealingy3cmydilation
C.yBiophysicalyprofileyresultsyshowingyoligohydramnios
D.yFetalyheartytonesylocatedyinyupperyrightyquadrantsy-yCORRECTyyANSWER-
D.yFetalyheartytonesylocatedyinyupperyrightyquadrants
Ay62-year-oldymaleyclientytellsytheynurseythatyheyhasyayhigh-
densityylipoproteiny(HDL)ylevelyofy85ymg/dl.yWhichyactionyshouldytheynurseytake?
A.yEncourageytheyclientytoyreduceyconsumptionyofyfattyyfoods
B.yAskytheyclientyaboutyhereditaryycardiacyriskyfactors
C.yConfirmythatythisyvalueyisyhelpfulyinyreducingycardiacyrisk
D.yExplainythatytheyclientymayyneedymedicationytherapyy-yCORRECTyyANSWER-
C.yConfirmythatythisyvalueyisyhelpingyinyreducingycardiacyrisk
Aychildynewlyydiagnosedywithysickleycellyanemiay(SCA)yisybeingydischargedyfromytheyhosp
ital.yWhichyinformationyisymostyimportantyforytheynurseytoyprovideytheyparentsypriorytoydisc
harge?
A.ySignsyofyaddictionytoyopioidypainymedication
B.yInformationyaboutynon-pharmaceuticalypainyreliefymeasures
C.yReferralyforysocialyservicesyforytheychildyandyfamily
D.yInstructionsyaboutyhowymuchyfluidytheychildyshouldydrinky-yCORRECTyyANSWER-
D.yInstructionsyaboutyhowymuchyfluidytheychildyshouldydrink
Ayclientyarrivesyforyanyannualyphysicalyexamyandycomplainsyofyhavingycalfypain.yTheyclient
'syhealthyhistoryyrevealsyperipheralyarterialydisease.yWhichyquestionyshouldytheynurseyask
ytheyclientyaboutyexpectedyfindingsyrelatedytoychronicyarterialysymptoms?
A.yWereyyourylegsyeverysuddenlyyswollen,yred,ywarm,yandypainful?
B.yDoesytheycalfypainyoccurywhenywalkingyshortydistances?
C.yDidyyouyreceiveytreatmentyforyweepingyulcersyonylowerylegs?
D.yHaveyyouyexperiencedyankleyedemayandyvaricoseyveins?y-yCORRECTyyANSWER-
B.yDoesytheycalfypainyoccurywhenywalkingyshortydistances?
Ayclientydevelopsyurticariayonytheytrunkyandyneckyshortlyyafteryaysecondaryyinfusionyofypip
eracillinyisyinitiated.yInywhatyorderyshouldytheynurseyimplementytheseyinterventions?y-
yCORRECTyyANSWER-1.yStopytheyinfusion
2.yAssessyvitalysigns
3.yContactytheyhealthcareyprovider
4.yDocumentyreactionytoytheydrug
5.yInitiateyanyadverseyeventyreport
AyclientyhasybothyayprimaryyIVyinfusionyandyaysecondaryyinfusionyofymedication.yAnyinfusio
nypumpyisynotyavailable.yTheynurseyneedsytoychangeytheyrateyofyflowyofytheysecondaryyinfu
sion.yWhereyshouldytheynurseyregulateytheyrateyofytheysecondaryyIV?y-
yCORRECTyyANSWER-
,Ayclientyisyadmittedywithyacuteypancreatitis.yTheyclientyadmitsytoydrinkingyaypintyofybourbon
ydaily.yTheynurseymedicatesytheyclientyforypainyandymonitorsyvitalysignsyeveryy2yhours.yWh
ichyfindingyshouldytheynurseyreportyimmediatelyytoytheyhealthcareyprovider?
A.yAnorexiayandyabdominalydistention
B.yAbdominalypainyandyvomiting
C.yConfusionyandytremors
D.yYellowingyandyitchingyofyskiny-yCORRECTyyANSWER-C.yConfusionyandytremors
AyclientyisyadmittedywithyanyexacerbationyofyheartyfailureysecondaryytoyCOPD.yWhichyobs
ervationsybyytheynurseyrequireyimmediateyinterventionytoyreduceytheylikelihoodyofyharmytoy
thisyclient?
A.yAybedsideycommodeyisypositionedynearytheybed
B.yAysalineylockyisypresentyinytheyrightyforearm
C.yAyfullypitcheryofywateryisyonytheybedsideytable
D.yAylowysodiumydietytrayywasybroughtytoytheyroom
E.yTheyclientyisylyingyinyaysupineypositionyinybedy-yCORRECTyyANSWER-
C.yAyfullypitcheryofywateryisyonytheybedsideytable
E.yTheyclientyisylyingyinyaysupineypositionyinybed
AyclientyisyadmittedywithytheydiagnosisyofyWernicke'sysyndrome.yWhichyassessmentyfindin
gyshouldytheynurseyuseyinyplanningytheyclient'sycare?
A.yDepression
B.yPeripheralyneuropathy
C.yConfusion
D.yRightyloweryabdominalypainy-yCORRECTyyANSWER-C.yConfusion
Ayclientyisyreceivingyaynitroglycerinyinfusionyaty20ymcg/min.yTheypharmacyydispensesyanyI
Vysolutionyofynitroglyceriny75ymgyiny250yD5W.yTheynurseyshouldyprogramytheyinfusionypu
mpytoydeliveryhowymanyymL/hr?y-yCORRECTyyANSWER-
pumpyrateyisymL/hry(soyweyhaveytoyconvertyminytoyhr)
Doseyreceivedy=y20mcg/min=y1200mcg/hry=y1.2mg/hr
toyknowyhowymuchymLyiny1.2ymg,yweyuseytheyfixedysolutiony75ymgyiny250ymLyasyayreferen
ce.y
75mgy---y250mL
1.2mgy--yXymL
Xy=y1.2yxy250/75y=y4ymL/hr
AyclientyisyreceivingyIVyheparinyandyoralywarfarinyafteryaypulmonaryyembolismy(PE).yTheyn
urseydeterminesytheyclient'syactivatedypartialyprothromboplastinytimey(aPTT)yvalueyisytwoyt
imesytheycontrolyvalue;ytheyprothrombinytimey(PT)ylevelyisytheysameyasytehycontrol,yandyth
eyinternationalynormalizedyratioy(INR)yisy1.yWhichyprotocolyprescriptionyshouldytheynurseyi
mplement?
A.yWithholdytheyheparinyandycontinueytheysameydoseyofywarfarin
B.yIncreaseytheywarfarinydose
C.yDecreaseytheyheparinydose
, D.yIncreaseytheyheparinydoseyandydecreaseytheywarfarinydosey-yCORRECTyyANSWER-
B.yIncreaseytheywarfarinydose
Ayclientywhoyhadybariatricysurgeryy2ymonthsyagoyisyadmittedybecauseyofyvomitingyandyina
bilityytoytolerateyfoodyandyliquids.yTheyclientyisypainyfree.yWhichyinterventionyshouldytheynu
rseyincludeyinytheyclient'syplanyofycare?
A.yDetermineyifytheyclientyisyover-hydratingytoyfeelysatiated
B.yMaintainytheyclientyonyanyNPOystatus
C.yEncourageypositiveyselfyaccoladesyforydietaryyadherence
D.yAdministerydailyyvitaminysupplementsy-yCORRECTyyANSWER-
B.yMaintainytheyclientyonyanyNPOystatus
Ayclientywhoyisyadmittedytoytheyintensiveycareyunitywithysyndromeyofyinappropriateyantidiur
eticyhormoney(SIADH)yhasydevelopedyosmoticydemyelination.yWhichyinterventionyshouldy
theynurseyimplementyfirst?
A.yPatchyoneyeye
B.yEvaluateyswallow
C.yReorientyoften
D.yRangeyofymotiony-yCORRECTyyANSWER-B.yEvaluateyswallow
Ayclientywhoyreceivedyhemodialysisyyesterdayyisyexperiencingyaybloodypressureyofy200/10
0ymmHg,yheartyratey110ybeats/minute,yandyrespiratoryyratey36ybreaths/minute.yTheyclienty
isymanifestingyshortnessyofybreath,ybilateraly2+ypedalyedema,yandyanyoxygenysaturationyo
nyroomyairyofy89%.yWhichyactionyshouldytheynurseytakeyfirst?
A.yElevateytheyfootyofytheybed
B.yRestrictytheyclient'syfluids
C.yBeginysupplementalyoxygen
D.yPrepareyclientyforyhemodialysisy-yCORRECTyyANSWER-
C.yBeginysupplementalyoxygen
AyclientywithyayC-
6yspinalycordyinjuryyisyinyrehabilitation.yInytheymiddleyofytheynightytheyclientyreportsyaysever
e,ypoundingyheadache,yandyhasyobservableypiloerectionyory"gooseybumps".yTheynurseysh
ouldyassessyforywhichytrigger?y
A.yLoudyhallwayynoise
B.yFrequentycough
C.yFever
D.yFullybladdery-yCORRECTyyANSWER-D.yFullybladder
Ayclientywithyayhistoryyofyschizophreniayisyadmittedywithydiabeticyketoacidosisy(DKA).yWhi
chynursingyinterventionsyshouldytheynurseyimplementyduringytheyadmissionyprocessyforythi
syclient?y
A.yObtainypsychiatricyandymedicalyadmissionyrecords
B.yHoldypsychotropicymedicationsyuntilyglucoseyisyregulatedy
C.yInterviewyclientyaboutyreasonyforyadmissionytoyhospital
D.yPrepareytheyclientyforyinvoluntaryycommitmentyadmission
Answers
Ay12-year-
oldyclientywhoyhadyanyappendectomyytwoydaysyagoyisyreceivingy0.9%ynormalysalineyaty50
mL/hr.yTheyclient'syurineyspecificygravityyisy1.035.yWhichyactionyshouldytheynurseyimpleme
nt?y
A.yAssessybowelysoundsyinyallyquadrants
B.yEncourageypopsiclesyandyfluidsyofychoice
C.yEvaluateyposturalybloodypressureymeasurements
D.yObtainyayspecimenyforyurinalysisy-yCORRECTyyANSWER-
B.yEncourageypopsiclesyandyfluidsyofychoice
Ay3-year-
oldyboyywasysuccessfullyytoiletytrainedypriorytoyhisyadmissionytoytheyhospitalyforyinjuriesysu
stainedyfromyayfall.yHisyparentsyareyveryyconcernedythatytheychildyhasyregressedyinyhisytoil
etingybehaviors.yWhichyinformationyshouldytheynurseyprovideytoytheyparents?
A.yDiaperingywillybeyprovidedysinceyhospitalizationyisystressfulytoypreschoolers
B.yChildrenyusuallyyresumeytheirytoiletingybehaviorsywhenytheyyleaveytheyhospital
C.yAypottyychairyshouldybeybroughtyfromyhomeysoyheycanymaintainyhisytoiletingyskills
D.yAyretrainingyprogramywillyneedytoybeyinitiatedywhenytheychildyreturnsyhomey-
yCORRECTyyANSWER-
B.yChildrenyusuallyyresumeytheirytoiletingybehaviorsywhenytheyyleaveytheyhospital
Ay3-year-
oldyboyywithyaycongenitalyheartydefectyisybroughtytoytheyclinicybyyhisymotherybecauseyheyh
asyayfeveryandyanyearache.yDuringytheyassessment,ytheymotheryasksytheynurseywhyyheryc
hildyisyatythey5thypercentileyforyweightyandyheightyforyhisyage.yWhichyresponseyisybestyforyt
heynurseytoyprovide?
A.y"Doesyyourychildyseemymentallyyslowerythanyhisypeersyalso?"
B.y"Haven'tyyouybeenyfeedingyhimyaccordingytoyrecommendedydailyyallowancesyforychildr
en?"
C.y"Hisysmallerysizeyisyprobablyydueytoytheyheartydisease"
D.y"Youyshouldynotyworryyaboutytheygrowthytables.yTheyyareyonlyyaveragesyforychildren."y-
yCORRECTyyANSWER-C.y"Hisysmallerysizeyisyprobablyydueytoytheyheartydisease"
Ay41-
weekygestationyprimigravidaywomanyisyadmittedytoylaboryandydeliveryyforyinductionyofylabo
r.yWhichyfindingyshouldytheynurseyreportytoytheyhealthcareyproviderybeforeyinitiatingytheyinf
usionyofyoxytocin?
A.yRegularycontractionsyoccurringyeveryy10yminutes
,B.ySterileyvaginalyexamyrevealingy3cmydilation
C.yBiophysicalyprofileyresultsyshowingyoligohydramnios
D.yFetalyheartytonesylocatedyinyupperyrightyquadrantsy-yCORRECTyyANSWER-
D.yFetalyheartytonesylocatedyinyupperyrightyquadrants
Ay62-year-oldymaleyclientytellsytheynurseythatyheyhasyayhigh-
densityylipoproteiny(HDL)ylevelyofy85ymg/dl.yWhichyactionyshouldytheynurseytake?
A.yEncourageytheyclientytoyreduceyconsumptionyofyfattyyfoods
B.yAskytheyclientyaboutyhereditaryycardiacyriskyfactors
C.yConfirmythatythisyvalueyisyhelpfulyinyreducingycardiacyrisk
D.yExplainythatytheyclientymayyneedymedicationytherapyy-yCORRECTyyANSWER-
C.yConfirmythatythisyvalueyisyhelpingyinyreducingycardiacyrisk
Aychildynewlyydiagnosedywithysickleycellyanemiay(SCA)yisybeingydischargedyfromytheyhosp
ital.yWhichyinformationyisymostyimportantyforytheynurseytoyprovideytheyparentsypriorytoydisc
harge?
A.ySignsyofyaddictionytoyopioidypainymedication
B.yInformationyaboutynon-pharmaceuticalypainyreliefymeasures
C.yReferralyforysocialyservicesyforytheychildyandyfamily
D.yInstructionsyaboutyhowymuchyfluidytheychildyshouldydrinky-yCORRECTyyANSWER-
D.yInstructionsyaboutyhowymuchyfluidytheychildyshouldydrink
Ayclientyarrivesyforyanyannualyphysicalyexamyandycomplainsyofyhavingycalfypain.yTheyclient
'syhealthyhistoryyrevealsyperipheralyarterialydisease.yWhichyquestionyshouldytheynurseyask
ytheyclientyaboutyexpectedyfindingsyrelatedytoychronicyarterialysymptoms?
A.yWereyyourylegsyeverysuddenlyyswollen,yred,ywarm,yandypainful?
B.yDoesytheycalfypainyoccurywhenywalkingyshortydistances?
C.yDidyyouyreceiveytreatmentyforyweepingyulcersyonylowerylegs?
D.yHaveyyouyexperiencedyankleyedemayandyvaricoseyveins?y-yCORRECTyyANSWER-
B.yDoesytheycalfypainyoccurywhenywalkingyshortydistances?
Ayclientydevelopsyurticariayonytheytrunkyandyneckyshortlyyafteryaysecondaryyinfusionyofypip
eracillinyisyinitiated.yInywhatyorderyshouldytheynurseyimplementytheseyinterventions?y-
yCORRECTyyANSWER-1.yStopytheyinfusion
2.yAssessyvitalysigns
3.yContactytheyhealthcareyprovider
4.yDocumentyreactionytoytheydrug
5.yInitiateyanyadverseyeventyreport
AyclientyhasybothyayprimaryyIVyinfusionyandyaysecondaryyinfusionyofymedication.yAnyinfusio
nypumpyisynotyavailable.yTheynurseyneedsytoychangeytheyrateyofyflowyofytheysecondaryyinfu
sion.yWhereyshouldytheynurseyregulateytheyrateyofytheysecondaryyIV?y-
yCORRECTyyANSWER-
,Ayclientyisyadmittedywithyacuteypancreatitis.yTheyclientyadmitsytoydrinkingyaypintyofybourbon
ydaily.yTheynurseymedicatesytheyclientyforypainyandymonitorsyvitalysignsyeveryy2yhours.yWh
ichyfindingyshouldytheynurseyreportyimmediatelyytoytheyhealthcareyprovider?
A.yAnorexiayandyabdominalydistention
B.yAbdominalypainyandyvomiting
C.yConfusionyandytremors
D.yYellowingyandyitchingyofyskiny-yCORRECTyyANSWER-C.yConfusionyandytremors
AyclientyisyadmittedywithyanyexacerbationyofyheartyfailureysecondaryytoyCOPD.yWhichyobs
ervationsybyytheynurseyrequireyimmediateyinterventionytoyreduceytheylikelihoodyofyharmytoy
thisyclient?
A.yAybedsideycommodeyisypositionedynearytheybed
B.yAysalineylockyisypresentyinytheyrightyforearm
C.yAyfullypitcheryofywateryisyonytheybedsideytable
D.yAylowysodiumydietytrayywasybroughtytoytheyroom
E.yTheyclientyisylyingyinyaysupineypositionyinybedy-yCORRECTyyANSWER-
C.yAyfullypitcheryofywateryisyonytheybedsideytable
E.yTheyclientyisylyingyinyaysupineypositionyinybed
AyclientyisyadmittedywithytheydiagnosisyofyWernicke'sysyndrome.yWhichyassessmentyfindin
gyshouldytheynurseyuseyinyplanningytheyclient'sycare?
A.yDepression
B.yPeripheralyneuropathy
C.yConfusion
D.yRightyloweryabdominalypainy-yCORRECTyyANSWER-C.yConfusion
Ayclientyisyreceivingyaynitroglycerinyinfusionyaty20ymcg/min.yTheypharmacyydispensesyanyI
Vysolutionyofynitroglyceriny75ymgyiny250yD5W.yTheynurseyshouldyprogramytheyinfusionypu
mpytoydeliveryhowymanyymL/hr?y-yCORRECTyyANSWER-
pumpyrateyisymL/hry(soyweyhaveytoyconvertyminytoyhr)
Doseyreceivedy=y20mcg/min=y1200mcg/hry=y1.2mg/hr
toyknowyhowymuchymLyiny1.2ymg,yweyuseytheyfixedysolutiony75ymgyiny250ymLyasyayreferen
ce.y
75mgy---y250mL
1.2mgy--yXymL
Xy=y1.2yxy250/75y=y4ymL/hr
AyclientyisyreceivingyIVyheparinyandyoralywarfarinyafteryaypulmonaryyembolismy(PE).yTheyn
urseydeterminesytheyclient'syactivatedypartialyprothromboplastinytimey(aPTT)yvalueyisytwoyt
imesytheycontrolyvalue;ytheyprothrombinytimey(PT)ylevelyisytheysameyasytehycontrol,yandyth
eyinternationalynormalizedyratioy(INR)yisy1.yWhichyprotocolyprescriptionyshouldytheynurseyi
mplement?
A.yWithholdytheyheparinyandycontinueytheysameydoseyofywarfarin
B.yIncreaseytheywarfarinydose
C.yDecreaseytheyheparinydose
, D.yIncreaseytheyheparinydoseyandydecreaseytheywarfarinydosey-yCORRECTyyANSWER-
B.yIncreaseytheywarfarinydose
Ayclientywhoyhadybariatricysurgeryy2ymonthsyagoyisyadmittedybecauseyofyvomitingyandyina
bilityytoytolerateyfoodyandyliquids.yTheyclientyisypainyfree.yWhichyinterventionyshouldytheynu
rseyincludeyinytheyclient'syplanyofycare?
A.yDetermineyifytheyclientyisyover-hydratingytoyfeelysatiated
B.yMaintainytheyclientyonyanyNPOystatus
C.yEncourageypositiveyselfyaccoladesyforydietaryyadherence
D.yAdministerydailyyvitaminysupplementsy-yCORRECTyyANSWER-
B.yMaintainytheyclientyonyanyNPOystatus
Ayclientywhoyisyadmittedytoytheyintensiveycareyunitywithysyndromeyofyinappropriateyantidiur
eticyhormoney(SIADH)yhasydevelopedyosmoticydemyelination.yWhichyinterventionyshouldy
theynurseyimplementyfirst?
A.yPatchyoneyeye
B.yEvaluateyswallow
C.yReorientyoften
D.yRangeyofymotiony-yCORRECTyyANSWER-B.yEvaluateyswallow
Ayclientywhoyreceivedyhemodialysisyyesterdayyisyexperiencingyaybloodypressureyofy200/10
0ymmHg,yheartyratey110ybeats/minute,yandyrespiratoryyratey36ybreaths/minute.yTheyclienty
isymanifestingyshortnessyofybreath,ybilateraly2+ypedalyedema,yandyanyoxygenysaturationyo
nyroomyairyofy89%.yWhichyactionyshouldytheynurseytakeyfirst?
A.yElevateytheyfootyofytheybed
B.yRestrictytheyclient'syfluids
C.yBeginysupplementalyoxygen
D.yPrepareyclientyforyhemodialysisy-yCORRECTyyANSWER-
C.yBeginysupplementalyoxygen
AyclientywithyayC-
6yspinalycordyinjuryyisyinyrehabilitation.yInytheymiddleyofytheynightytheyclientyreportsyaysever
e,ypoundingyheadache,yandyhasyobservableypiloerectionyory"gooseybumps".yTheynurseysh
ouldyassessyforywhichytrigger?y
A.yLoudyhallwayynoise
B.yFrequentycough
C.yFever
D.yFullybladdery-yCORRECTyyANSWER-D.yFullybladder
Ayclientywithyayhistoryyofyschizophreniayisyadmittedywithydiabeticyketoacidosisy(DKA).yWhi
chynursingyinterventionsyshouldytheynurseyimplementyduringytheyadmissionyprocessyforythi
syclient?y
A.yObtainypsychiatricyandymedicalyadmissionyrecords
B.yHoldypsychotropicymedicationsyuntilyglucoseyisyregulatedy
C.yInterviewyclientyaboutyreasonyforyadmissionytoyhospital
D.yPrepareytheyclientyforyinvoluntaryycommitmentyadmission
