FINAL HESI EXIT EXAM
QUESTIONS AND ANSWERS
The77nurse77assumes77care77of77a77postoperative77adult77client77with77type77277diabetes77mellitus77a
nd77learns77that77the77client77has77a77current77blood77glucose77level77of7775077mg/dL.77(4277mmol/L)
.77When77assessing77the77client,77what77is77the77priority?
A) Assess77for77signs77of77fluid77volume77deficit.
B) Observe77wound77drainage77characteristics.
C) Measure77the77level77of77acute77pain.
D) Determine77when77the77client77last77ate.77-77CORRECT77ANSWER77-
A)77Assess77for77signs77of77fluid77volume77deficit.
A77male77client77tells77the77nurse77that77he77is77concerned77that77he77may77have77a77stomach77ulcer,
77because77he77is77experiencing77heartburn77and77a77dull77gnawing77pain77that77is77relieved77when77
he77eats.77Which77is77the77best77response77by77the77nurse?
A) Encourage77the77client77to77obtain77a77complete77physical77exam,77since77these77symptoms77are7
7consistent77with77an77ulcer.
B) Assure77the77client77that77his77symptoms77may77only77reflect77reflux,77since77ulcer77pain77is77not77reliev
ed77with77food.
C) Instruct77the77client77that77these77mild77symptoms77can77generally77be77controlled77with77changed77in77
his77diet.
D) Advise77the77client77that77he77needs77to77seek77immediate77medical77evaluation77and77treatment77
of77these77symptoms.77-77CORRECT77ANSWER77-
A)77Encourage77the77client77to77obtain77a77complete77physical77exam,77since77these77symptoms77are77
consistent77with77an77ulcer.
A77male77client77with77stomach77cancer77returns77to77the77unit77following77a77total77gastrectomy.77He
77has77a77nasogastric77tube77to77suction77and77is77receiving77Lactated77Ringer's77solution77at777577mL/
hour77IV.77One77hour77after77admission77to77the77unit,77the77nurse77notes7730077mL77of77blood77in77t
he77suction77canister,77the77client's77heart77rate77is77155bpm,77and
,his77blood77pressure77is7778/4877mmHg.77In77addition77to77reporting77the77findings77to77the77surgeon,
77which77action77should77the77nurse77implement77first?
A) Measure77and77document77the77client's77urinary77output.
B) Request77the77client's77reserved77unit77of77packed77red77blood77cells.
C) prepare77for77placement77of77a77central77venous77catheter.
D) Increase77the77infusion77rate77of77Lactated77Ringer's77solution.77-77CORRECT77ANSWER77-
D)77Increase77the77infusion77rate77of77Lactated77Ringer's77solution.
A77heparin77infusion77is77prescribed77for77a77client77who77weighs7722077pounds.77After77adminstering
77a77bolus77dose77of778077units/kg,77the77nurse77calculates77the77infusion77rate77for77the77heparin77so
lution77at771877units/kg/hour.77the77available77solution77is77Heparin77Sodium7725,00077Units77in775%77
Dextrose77Injection77250mL.77The77nurse77should77program77the77infusion77pump77to77deliver77how77
many77ml/hour?77Round77to77nearest77whole77number77if77necessary.
-77CORRECT77ANSWER77-18
An77adult77male77who77fell772077feet77from77the77roof77of77his77home77has77multiple77injuries,77inclu
ding77a77right77pneumothorax.77Chest77tubes77were77inserted77in77the77emergency77department77pri
or77to77his77transfer77to77the77intensive77care77unit77(ICU).77The77nurse77notes77that77the77suction77c
ontrol77chamber77is77bubbling77at77the77-
2077cm77H2O77mark,77with77fluctuation77in77the77water77seal,77and77over77the77past77hour777577mL77
of77bright77red77blood77is77measured77in77the77collection77chamber.77Which77intervention77should77t
he77nurse77implement?
A) Add77sterile77water77to77the77suction77control77chamber.
B) Give77blood77from77the77collection77chamber77as77autotransfusion.
C) Manipulate77blood77tubing77to77drain77into77chamber.
D) Increase77wall77suction77to77eliminate77fluctuation77in77water77seal.77-77CORRECT77ANSWER77-
A)77Add77sterile77water77to77the77suction77control77chamber.
An77adult77male77was77diagnosed77with77stage77IV77lung77cancer77three77weeks77ago.77His77wife77app
roaches77the77nurse77and77asks77how77she77will77know77that77her77husband's77death77is77imminent77b
ecause77their77two77children77want77to77be77there77when77he77dies.77Which77is77the77best77response7
7by77the77nurse?
,A) Gather77information77regarding77how77long77it77will77take77for77the77children77to77arrive.
B) Explain77that77the77client77will77start77to77lose77consciousness77and77the77body77systems77will77slow77do
wn.
C) Reassure77the77spouse77that77the77healthcare77provider77will77notify77when77to77call77the77children.
D) Offer77to77discuss77the77client's77health77status77with77each77of77the77adult77children.77-
77CORRECT77ANSWER77-
B)77Explain77that77the77client77will77start77to77lose77consciousness77and77the77body77systems77wil
l77slow77down.
The77charge77nurse77of77a77critical77care77unit77is77informed77at77the77beginning77of77the77shift77that77
less77than77the77optimal77number77of77registered77nurses77will77be77working77that77shift.77In77plannin
g77assignments,77which77client77should77receive77the77most77care77hours77by77a77registered77nurse77(
RN)?
A) A7748-year-
old77marathon77runner77with77a77central77venous77catheter77who77is77experiencing77nausea77an
d77vomiting77due77to77electrolyte77disturbance77following77a77race.
B) A7734-year-
old77admitted77today77after77an77emergency77appendectomy77who77has77a77peripheral77intravenous
77catheter77and77a77Foley77catheter.
C) A7763-year-
old77chain77smoker77admitted77with77chronic77bronchitis77who77is77receiving77oxygen77via77nas
al77cannula77and77has77a77saline-locked77peripheral77intravenous77catheter.
D) An7782-year-old77client77with77Alzheimer's77disease77and77a77newly-
fractured77femur77who77has77a77Foley77catheter77and77soft77wrist77restraints77applied.77-
77CORRECT77ANSWER77-D)77An7782-year-old77client77with77Alzheimer's77disease77and77a77newly-
fractured77femur77who77has77a77Foley77catheter77and77soft77wrist77restraints77applied.
The77nurse77is77preparing77a77dose77of776077mcg77of77teriparatide.77The77medication77is77labeled77"75
077mcg/2/477mL."77How77many77mL77should77the77nurse77administer?77if77needed,77round77to77the77n
earest77tenth.)77-77CORRECT77ANSWER
-0.2
In77caring77for77a77client77with77Cushing's77syndrome,77which77serum77laboratory77value77is77most77i
mportant77for77the77nurse77to77monitor?
, A) Creatinine
B) Lactate
C) Glucose
QUESTIONS AND ANSWERS
The77nurse77assumes77care77of77a77postoperative77adult77client77with77type77277diabetes77mellitus77a
nd77learns77that77the77client77has77a77current77blood77glucose77level77of7775077mg/dL.77(4277mmol/L)
.77When77assessing77the77client,77what77is77the77priority?
A) Assess77for77signs77of77fluid77volume77deficit.
B) Observe77wound77drainage77characteristics.
C) Measure77the77level77of77acute77pain.
D) Determine77when77the77client77last77ate.77-77CORRECT77ANSWER77-
A)77Assess77for77signs77of77fluid77volume77deficit.
A77male77client77tells77the77nurse77that77he77is77concerned77that77he77may77have77a77stomach77ulcer,
77because77he77is77experiencing77heartburn77and77a77dull77gnawing77pain77that77is77relieved77when77
he77eats.77Which77is77the77best77response77by77the77nurse?
A) Encourage77the77client77to77obtain77a77complete77physical77exam,77since77these77symptoms77are7
7consistent77with77an77ulcer.
B) Assure77the77client77that77his77symptoms77may77only77reflect77reflux,77since77ulcer77pain77is77not77reliev
ed77with77food.
C) Instruct77the77client77that77these77mild77symptoms77can77generally77be77controlled77with77changed77in77
his77diet.
D) Advise77the77client77that77he77needs77to77seek77immediate77medical77evaluation77and77treatment77
of77these77symptoms.77-77CORRECT77ANSWER77-
A)77Encourage77the77client77to77obtain77a77complete77physical77exam,77since77these77symptoms77are77
consistent77with77an77ulcer.
A77male77client77with77stomach77cancer77returns77to77the77unit77following77a77total77gastrectomy.77He
77has77a77nasogastric77tube77to77suction77and77is77receiving77Lactated77Ringer's77solution77at777577mL/
hour77IV.77One77hour77after77admission77to77the77unit,77the77nurse77notes7730077mL77of77blood77in77t
he77suction77canister,77the77client's77heart77rate77is77155bpm,77and
,his77blood77pressure77is7778/4877mmHg.77In77addition77to77reporting77the77findings77to77the77surgeon,
77which77action77should77the77nurse77implement77first?
A) Measure77and77document77the77client's77urinary77output.
B) Request77the77client's77reserved77unit77of77packed77red77blood77cells.
C) prepare77for77placement77of77a77central77venous77catheter.
D) Increase77the77infusion77rate77of77Lactated77Ringer's77solution.77-77CORRECT77ANSWER77-
D)77Increase77the77infusion77rate77of77Lactated77Ringer's77solution.
A77heparin77infusion77is77prescribed77for77a77client77who77weighs7722077pounds.77After77adminstering
77a77bolus77dose77of778077units/kg,77the77nurse77calculates77the77infusion77rate77for77the77heparin77so
lution77at771877units/kg/hour.77the77available77solution77is77Heparin77Sodium7725,00077Units77in775%77
Dextrose77Injection77250mL.77The77nurse77should77program77the77infusion77pump77to77deliver77how77
many77ml/hour?77Round77to77nearest77whole77number77if77necessary.
-77CORRECT77ANSWER77-18
An77adult77male77who77fell772077feet77from77the77roof77of77his77home77has77multiple77injuries,77inclu
ding77a77right77pneumothorax.77Chest77tubes77were77inserted77in77the77emergency77department77pri
or77to77his77transfer77to77the77intensive77care77unit77(ICU).77The77nurse77notes77that77the77suction77c
ontrol77chamber77is77bubbling77at77the77-
2077cm77H2O77mark,77with77fluctuation77in77the77water77seal,77and77over77the77past77hour777577mL77
of77bright77red77blood77is77measured77in77the77collection77chamber.77Which77intervention77should77t
he77nurse77implement?
A) Add77sterile77water77to77the77suction77control77chamber.
B) Give77blood77from77the77collection77chamber77as77autotransfusion.
C) Manipulate77blood77tubing77to77drain77into77chamber.
D) Increase77wall77suction77to77eliminate77fluctuation77in77water77seal.77-77CORRECT77ANSWER77-
A)77Add77sterile77water77to77the77suction77control77chamber.
An77adult77male77was77diagnosed77with77stage77IV77lung77cancer77three77weeks77ago.77His77wife77app
roaches77the77nurse77and77asks77how77she77will77know77that77her77husband's77death77is77imminent77b
ecause77their77two77children77want77to77be77there77when77he77dies.77Which77is77the77best77response7
7by77the77nurse?
,A) Gather77information77regarding77how77long77it77will77take77for77the77children77to77arrive.
B) Explain77that77the77client77will77start77to77lose77consciousness77and77the77body77systems77will77slow77do
wn.
C) Reassure77the77spouse77that77the77healthcare77provider77will77notify77when77to77call77the77children.
D) Offer77to77discuss77the77client's77health77status77with77each77of77the77adult77children.77-
77CORRECT77ANSWER77-
B)77Explain77that77the77client77will77start77to77lose77consciousness77and77the77body77systems77wil
l77slow77down.
The77charge77nurse77of77a77critical77care77unit77is77informed77at77the77beginning77of77the77shift77that77
less77than77the77optimal77number77of77registered77nurses77will77be77working77that77shift.77In77plannin
g77assignments,77which77client77should77receive77the77most77care77hours77by77a77registered77nurse77(
RN)?
A) A7748-year-
old77marathon77runner77with77a77central77venous77catheter77who77is77experiencing77nausea77an
d77vomiting77due77to77electrolyte77disturbance77following77a77race.
B) A7734-year-
old77admitted77today77after77an77emergency77appendectomy77who77has77a77peripheral77intravenous
77catheter77and77a77Foley77catheter.
C) A7763-year-
old77chain77smoker77admitted77with77chronic77bronchitis77who77is77receiving77oxygen77via77nas
al77cannula77and77has77a77saline-locked77peripheral77intravenous77catheter.
D) An7782-year-old77client77with77Alzheimer's77disease77and77a77newly-
fractured77femur77who77has77a77Foley77catheter77and77soft77wrist77restraints77applied.77-
77CORRECT77ANSWER77-D)77An7782-year-old77client77with77Alzheimer's77disease77and77a77newly-
fractured77femur77who77has77a77Foley77catheter77and77soft77wrist77restraints77applied.
The77nurse77is77preparing77a77dose77of776077mcg77of77teriparatide.77The77medication77is77labeled77"75
077mcg/2/477mL."77How77many77mL77should77the77nurse77administer?77if77needed,77round77to77the77n
earest77tenth.)77-77CORRECT77ANSWER
-0.2
In77caring77for77a77client77with77Cushing's77syndrome,77which77serum77laboratory77value77is77most77i
mportant77for77the77nurse77to77monitor?
, A) Creatinine
B) Lactate
C) Glucose
