2025 HESI CRITICAL CARE EXIT EXAM TESTBANK 2
WITH 7 ACTUAL UPDATED VERSIONS
(V1,V2,V3,V4,V5,V6,V7) EACH VERSION COMPLETE
REAL verified QUESTIONS AND CORRECT
VERIFIED ANSWERS WITH detailed RATIONALES
Prepared by Joyce wanjiku
HESI RN EXIT EXAM 2023-2024 2025 LATEST VERSIONS
V1-V7 COMPLETE TEST BANK (WELL ORGANISED)/RN
HESI EXIT TEST BANK QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED A+(SCORE 1200)
, VERSION 1
1. A client who is first day postoperative after a mastectomy becomes increasingly restless
and agitated. Vital signs are temperature, 100° F; pulse, 98 beats/min; respirations, 24
breaths/min; and blood pressure, 120/80 mm Hg. Which intervention should the nurse
implement first?
A. Administer a PRN dose of a prescribed analgesic.
B. Assess the incision for any drainage or redness.
C. Instruct the UAP to take vital signs hourly.
D. Assist the client to a more comfortable position.
Rationale:
The nurse's priority is to observe for possible hemorrhage. The client is at high risk for
hypovolemic shock and is exhibiting early symptoms of shock. Remember, in early shock the
blood pressure may be stable or increase slightly as a compensatory mechanism. If there is
no obvious indication of bleeding, the client should then be assessed for the need of an
analgesic and options A, C, and D should be implemented.
2. A client is receiving propylthiouracil (PTU) prior to thyroid surgery. Which diagnostic test
results indicate that the medication is producing the desired effect?
A. Increased hemoglobin and hematocrit levels
B. Increased serum calcium level
C. Decreased white blood cell (WBC) count
D. Decreased triiodothyronine (T3) and thyroxine (T4) levels
Rationale:
Propylthiouracil (PTU) is an adjunct therapy used to control hyperthyroidism by inhibiting the
production of thyroid hormones. It is often prescribed in preparation for thyroidectomy or
radioactive iodine therapy. It does not affect option A. Option B must be monitored after
surgery in case the parathyroid glands were removed, but preoperative PTU does not
increase the serum calcium level. If the client has an infection preoperatively, antibiotics will
be given and option C monitored.
93. A client exhibits symptoms of alcohol intoxication. The blood alcohol level is 200 mg
,(0.2%). Which measurement tool is best for the nurse to use during the initial assessment of
this client?
a. CAGE questionnaire for alcoholism
b. Addiction Severity Index
c. Glasgow Coma Scale
d. DSM multiaxial evaluation
Rationale:
Evaluation of level of consciousness, which is the purpose of the Glasgow Coma Scale, has the
highest priority. Option A is useful in helping clients recognize their alcoholism. Options B and
D are comprehensive assessments that should be completed after the acute phase is
resolved.
94. A client with bipolar disorder is seen in the mental health clinic for evaluation of a
new medication regimen that includes risperidone. The nurse notes that the client has
gained 30 lb in the past 3 months. Which assessment is most important for the nurse to
obtain?
A. Compliance with medication regimen
, B. Current thyroid-stimulating hormone (TSH) level
C. Occurrence of mania or depression
D. A 24-hour diet and exercise recall
Rationale:
Medication compliance is most important for the treatment of psychotic disorders, and
because Risperidone is associated with weight gain, it is probable that the client is complying
with the treatment plan. The TSH level indicates thyroid function, which regulates basal
metabolic rate and influences weight. It is important to obtain information about occurrences
of mania and depression since the last visit, but if the client is compliant with the medication
regimen, these symptoms are likely to have been controlled. Diet and exercise should also be
assessed, but weight gain is a likely indicator of medication compliance.
5. A client is admitted to a mental health unit because of mild depression. When
asked, he denies suicidal ideation, but the nurse reads in the psychosocial assessment that
there were attempts to overdose on aspirin 5 years earlier. Which intervention is most
important for the nurse to implement?
A. Orient the client to activities on the unit.
B. Document suicide precautions on the shift report.
C. Assign the client to a semiprivate room.
D. Obtain a verbal no-suicide contract with the client.
Rationale:
It is most important to prevent the risk of self-harm from social isolation, so the client should
be assigned to a semiprivate room. Option A does not have the priority of option C. Options B
and D can be implemented if the client admits suicidal ideation. However, based on the fact
that this client is mildly depressed and that he attempted suicide 5 years ago using a
method that is usually nonlethal (aspirin overdose), it is most important to prevent social
isolation.
6. A couple expresses concern and fear prior to having an amniocentesis to determine
fetal lung maturity. To assist them in coping with this situation, which intervention is best for
the nurse to implement?
A. Explain that harm to the fetus is highly unlikely.
B. Answer all their questions regarding the procedure.
C. Encourage them to verbalize their feelings.
D. Show them a video about the procedure.
Rationale:
The nurse should allay their concerns by providing information about the procedure and
answering questions. This action assists the couple in coping with the situation. Option A may
offer false reassurance. Option C alone does not resolve the couple's fears. Although option D
may be helpful, it is a passive activity, and the nurse's availability to answer questions is likely
to be most helpful in calming their fears.
7. A client is receiving substitution therapy during withdrawal from benzodiazepines.
Which expected outcome statement has the highest priority when planning nursing care?
A. Client will not demonstrate cross addiction.
WITH 7 ACTUAL UPDATED VERSIONS
(V1,V2,V3,V4,V5,V6,V7) EACH VERSION COMPLETE
REAL verified QUESTIONS AND CORRECT
VERIFIED ANSWERS WITH detailed RATIONALES
Prepared by Joyce wanjiku
HESI RN EXIT EXAM 2023-2024 2025 LATEST VERSIONS
V1-V7 COMPLETE TEST BANK (WELL ORGANISED)/RN
HESI EXIT TEST BANK QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED A+(SCORE 1200)
, VERSION 1
1. A client who is first day postoperative after a mastectomy becomes increasingly restless
and agitated. Vital signs are temperature, 100° F; pulse, 98 beats/min; respirations, 24
breaths/min; and blood pressure, 120/80 mm Hg. Which intervention should the nurse
implement first?
A. Administer a PRN dose of a prescribed analgesic.
B. Assess the incision for any drainage or redness.
C. Instruct the UAP to take vital signs hourly.
D. Assist the client to a more comfortable position.
Rationale:
The nurse's priority is to observe for possible hemorrhage. The client is at high risk for
hypovolemic shock and is exhibiting early symptoms of shock. Remember, in early shock the
blood pressure may be stable or increase slightly as a compensatory mechanism. If there is
no obvious indication of bleeding, the client should then be assessed for the need of an
analgesic and options A, C, and D should be implemented.
2. A client is receiving propylthiouracil (PTU) prior to thyroid surgery. Which diagnostic test
results indicate that the medication is producing the desired effect?
A. Increased hemoglobin and hematocrit levels
B. Increased serum calcium level
C. Decreased white blood cell (WBC) count
D. Decreased triiodothyronine (T3) and thyroxine (T4) levels
Rationale:
Propylthiouracil (PTU) is an adjunct therapy used to control hyperthyroidism by inhibiting the
production of thyroid hormones. It is often prescribed in preparation for thyroidectomy or
radioactive iodine therapy. It does not affect option A. Option B must be monitored after
surgery in case the parathyroid glands were removed, but preoperative PTU does not
increase the serum calcium level. If the client has an infection preoperatively, antibiotics will
be given and option C monitored.
93. A client exhibits symptoms of alcohol intoxication. The blood alcohol level is 200 mg
,(0.2%). Which measurement tool is best for the nurse to use during the initial assessment of
this client?
a. CAGE questionnaire for alcoholism
b. Addiction Severity Index
c. Glasgow Coma Scale
d. DSM multiaxial evaluation
Rationale:
Evaluation of level of consciousness, which is the purpose of the Glasgow Coma Scale, has the
highest priority. Option A is useful in helping clients recognize their alcoholism. Options B and
D are comprehensive assessments that should be completed after the acute phase is
resolved.
94. A client with bipolar disorder is seen in the mental health clinic for evaluation of a
new medication regimen that includes risperidone. The nurse notes that the client has
gained 30 lb in the past 3 months. Which assessment is most important for the nurse to
obtain?
A. Compliance with medication regimen
, B. Current thyroid-stimulating hormone (TSH) level
C. Occurrence of mania or depression
D. A 24-hour diet and exercise recall
Rationale:
Medication compliance is most important for the treatment of psychotic disorders, and
because Risperidone is associated with weight gain, it is probable that the client is complying
with the treatment plan. The TSH level indicates thyroid function, which regulates basal
metabolic rate and influences weight. It is important to obtain information about occurrences
of mania and depression since the last visit, but if the client is compliant with the medication
regimen, these symptoms are likely to have been controlled. Diet and exercise should also be
assessed, but weight gain is a likely indicator of medication compliance.
5. A client is admitted to a mental health unit because of mild depression. When
asked, he denies suicidal ideation, but the nurse reads in the psychosocial assessment that
there were attempts to overdose on aspirin 5 years earlier. Which intervention is most
important for the nurse to implement?
A. Orient the client to activities on the unit.
B. Document suicide precautions on the shift report.
C. Assign the client to a semiprivate room.
D. Obtain a verbal no-suicide contract with the client.
Rationale:
It is most important to prevent the risk of self-harm from social isolation, so the client should
be assigned to a semiprivate room. Option A does not have the priority of option C. Options B
and D can be implemented if the client admits suicidal ideation. However, based on the fact
that this client is mildly depressed and that he attempted suicide 5 years ago using a
method that is usually nonlethal (aspirin overdose), it is most important to prevent social
isolation.
6. A couple expresses concern and fear prior to having an amniocentesis to determine
fetal lung maturity. To assist them in coping with this situation, which intervention is best for
the nurse to implement?
A. Explain that harm to the fetus is highly unlikely.
B. Answer all their questions regarding the procedure.
C. Encourage them to verbalize their feelings.
D. Show them a video about the procedure.
Rationale:
The nurse should allay their concerns by providing information about the procedure and
answering questions. This action assists the couple in coping with the situation. Option A may
offer false reassurance. Option C alone does not resolve the couple's fears. Although option D
may be helpful, it is a passive activity, and the nurse's availability to answer questions is likely
to be most helpful in calming their fears.
7. A client is receiving substitution therapy during withdrawal from benzodiazepines.
Which expected outcome statement has the highest priority when planning nursing care?
A. Client will not demonstrate cross addiction.
