HESI RN EXIT EXAM (II) QUESTIONS WITH COMPLETE SOLUTIONS
GUARANTEED PASS BRAND NEW 2025
After placing a 36- week- gestation newborn in an isolette and
drying the infant with several blankets, what should the nurse
implement next?
Remove the wet blankets and linen from the isolette
A client in the third trimester of pregnancy complains of frequent
nasal stiffness and occasional nosebleeds. Her chest circumference
has increased by 5 cm during the pregnancy, and she uses thoracic
breathing. Her diaphragm is elevated and she has an increased
costal angle. Which intervention should the nurse implement?
Record the respiratory finding in the clients chart as normal
A terminally ill male hospice client who is at home is showing
decreased awareness of his surroundings. His appetite is poor and
he often refuses oral intake of solids and liquids. For the past several
days he has been unable to get out of bed. Which action should the
hospice nurse implement?
Instruct family to offer client only soft bland foods
A woman was admitted yesterday afternoon with severe abdominal
pain. Her pregnancy test and ultrasound were negative, so an
exploratory laparotomy was completed during the night. When
coffee ground materials is observed in the drainage from the
,nasogastric tube (NGT), which intervention should the nurse
implement?
Verify correct placement of the nasogastric tube
The nurse is reviewing the laboratory values for a client with acute
pancreatitis who reports of the abdominal pain is not as severe as it
was on admission. Which laboratory test should the nurse review to
evaluate the clients clinical recovery?
Lipase
While assessing a client who had a laparotomy the previous day, the
nurse notices that 300 mL of dark red fluid has drained from the
nasogastric tube in the last hour. Which action should the nurse
take first?
take vital signs
The nurse is reviewing the recommended preventative care for
clients with asthma, chronic bronchitis, and emphysema. Which
health care measure is most important for the nurse to recommend
to these clients?
Avoid large crowded areas during the colder months of the year
The mother of a one-moth-old infant calls the clinic to report that
the back of her infant's head is flat. How should the nurse respond?
Position the infant on the stomach occasionally when awake and active
,A woman is brought to the labor and delivery unti after delivering a
term infant and the placenta in the hospital parking lot 10 minutes
ago. Which action should the nurse perform first?
Perform a fundal massage
A client has a new prescription for the maximum recommended
dosage of pipercillin/tazobactam for nosocomial pneumonia. The
nurse should report which laboratory finding to the healthcare
provider before administering the prescribed dose?
Decrease serum creatine
A client who is admitted with diabetic ketoacidosis (DKA) is
demonstrating Kussmaul breathing and has a severe headache along
with nausea. Her arterial blood gases (ABG) are: pH 7.50; PaCO2
30 mmHg; HCO3 24 mEq/L (24mmol/L). Which assessment finding
warrants immediate intervention by the nurse?
Fruity breath
When performing postural drainage on a client with Chronic
Obstructive Pulmonary disease (COPD), which approach should the
nurse use?
Explain that the client may be placed in five positions
A young male client with testicular cancer has a living will that
describes his desire that no extraordinary measures be taken to save
his life. The healthcare provider knows the client has a good
, prognosis and refuses to write a "do not resuscitate" (DNR)
prescription. Which action should the nurse take?
Initiate an ethics committee review
In observing a clients face, which assessment finding requires the
most immediate intervention by the nurse?
Oral mucosa is cyanotic Blue lips
The nurse is assessing a client with cirrhosis and notes that the client
has a positive Babinski reflex. Which action should the nurse take in
response to the finding?
Complete a thorough neurological assessment
Which action should the nurse take first after obtaining a urine
specimen for culture and sensitivity from an indwelling urinary
catheter?
Ensure continued sterility of the specimen container
The home health nurse observes an older client with unilateral
weakness place the walker in front of the chair for support while
rising to a standing position. Which action should the nurse take?
Hold the chair
A client with cancer complains of fever, chills, malaise, and
headache following administration of a colony-stimulating factor.
Which nursing intervention is most beneficial in helping to reduce
the flu like symptoms?
Monitor lab values for an increase in WBCs
GUARANTEED PASS BRAND NEW 2025
After placing a 36- week- gestation newborn in an isolette and
drying the infant with several blankets, what should the nurse
implement next?
Remove the wet blankets and linen from the isolette
A client in the third trimester of pregnancy complains of frequent
nasal stiffness and occasional nosebleeds. Her chest circumference
has increased by 5 cm during the pregnancy, and she uses thoracic
breathing. Her diaphragm is elevated and she has an increased
costal angle. Which intervention should the nurse implement?
Record the respiratory finding in the clients chart as normal
A terminally ill male hospice client who is at home is showing
decreased awareness of his surroundings. His appetite is poor and
he often refuses oral intake of solids and liquids. For the past several
days he has been unable to get out of bed. Which action should the
hospice nurse implement?
Instruct family to offer client only soft bland foods
A woman was admitted yesterday afternoon with severe abdominal
pain. Her pregnancy test and ultrasound were negative, so an
exploratory laparotomy was completed during the night. When
coffee ground materials is observed in the drainage from the
,nasogastric tube (NGT), which intervention should the nurse
implement?
Verify correct placement of the nasogastric tube
The nurse is reviewing the laboratory values for a client with acute
pancreatitis who reports of the abdominal pain is not as severe as it
was on admission. Which laboratory test should the nurse review to
evaluate the clients clinical recovery?
Lipase
While assessing a client who had a laparotomy the previous day, the
nurse notices that 300 mL of dark red fluid has drained from the
nasogastric tube in the last hour. Which action should the nurse
take first?
take vital signs
The nurse is reviewing the recommended preventative care for
clients with asthma, chronic bronchitis, and emphysema. Which
health care measure is most important for the nurse to recommend
to these clients?
Avoid large crowded areas during the colder months of the year
The mother of a one-moth-old infant calls the clinic to report that
the back of her infant's head is flat. How should the nurse respond?
Position the infant on the stomach occasionally when awake and active
,A woman is brought to the labor and delivery unti after delivering a
term infant and the placenta in the hospital parking lot 10 minutes
ago. Which action should the nurse perform first?
Perform a fundal massage
A client has a new prescription for the maximum recommended
dosage of pipercillin/tazobactam for nosocomial pneumonia. The
nurse should report which laboratory finding to the healthcare
provider before administering the prescribed dose?
Decrease serum creatine
A client who is admitted with diabetic ketoacidosis (DKA) is
demonstrating Kussmaul breathing and has a severe headache along
with nausea. Her arterial blood gases (ABG) are: pH 7.50; PaCO2
30 mmHg; HCO3 24 mEq/L (24mmol/L). Which assessment finding
warrants immediate intervention by the nurse?
Fruity breath
When performing postural drainage on a client with Chronic
Obstructive Pulmonary disease (COPD), which approach should the
nurse use?
Explain that the client may be placed in five positions
A young male client with testicular cancer has a living will that
describes his desire that no extraordinary measures be taken to save
his life. The healthcare provider knows the client has a good
, prognosis and refuses to write a "do not resuscitate" (DNR)
prescription. Which action should the nurse take?
Initiate an ethics committee review
In observing a clients face, which assessment finding requires the
most immediate intervention by the nurse?
Oral mucosa is cyanotic Blue lips
The nurse is assessing a client with cirrhosis and notes that the client
has a positive Babinski reflex. Which action should the nurse take in
response to the finding?
Complete a thorough neurological assessment
Which action should the nurse take first after obtaining a urine
specimen for culture and sensitivity from an indwelling urinary
catheter?
Ensure continued sterility of the specimen container
The home health nurse observes an older client with unilateral
weakness place the walker in front of the chair for support while
rising to a standing position. Which action should the nurse take?
Hold the chair
A client with cancer complains of fever, chills, malaise, and
headache following administration of a colony-stimulating factor.
Which nursing intervention is most beneficial in helping to reduce
the flu like symptoms?
Monitor lab values for an increase in WBCs
