2025 HESI RN Exit V2 160
QUESTIONS WITH VERIFIED
ANSWERS
The nurse assumes care of a postoperative adult client with type
2 diabetes mellitus and learns that the client has a current blood
glucose level of 720 mg/dL. When assessing the client, what is
the priority?
A. Assess for signs of fluid volume deficit
B. Observe wound drainage characteristics
C. Measure the level of acute pain
D. Determine when the client last ate
A. Assess for signs of fluid volume deficit
A male client tells the nurse that he is concerned that he may
have a stomach ulcer, because he is experiencing heartburn and
dull gnawing pain that is relieved when he eats. Which is the best
response by the nurse?
A. Encourage the client to obtain a complete physical exam, since
these symptoms are consistent with an ulcer
,B. Assure the client that his symptoms may only reflect reflux,
since ulcer pain is not relieved with food
C. Instruct the client that these mild symptoms can generally be
controlled with changes in his diet
D. Advise the client that he needs to seek immediate medical
evaluation and treatment of these symptoms
A. Encourage the client to obtain a complete physical exam,
since these symptoms are consistent with an ulcer
A male client with stomach cancer returns to the unit following a
total gastrectomy. He has a nasogastric tube to suction and is
receiving Lactated Ringer's solution at 75 mL/hr IV. One hour after
admission to the unit, the nurse notes 300mL of blood in the
suction canister, the client's heart rate is 155 beats/minute, and
his blood pressure is 78/48 mmHg. In addition to reporting the
findings to the surgeon, which action should the nurse implement
first?
A. Measure and document the client's urinary output
B. Request the client's reserved unit of packed red blood cells
C. Prepare for placement of a central venous catheter
D. Increase the infusion rate of Lactated Ringer's solution
D. Increase the infusion rate of Lactated Ringer's solution
,A heparin infusion is prescribed for a client who weighs 220
pounds. After administering a bolus dose of 80 units/kg, the
nurse calculates the infusion rate for the heparin solution as 18
units/kg/hour. The available solution is Heparin Sodium 25,000
Units in 5% Dextrose Injection 250 mL. The nurse should program
the infusion pump to deliver how many mL/hour?
-1st: calculate the weight = 220/2.2= 100kg
-Then calculate total dose in units = 18units x 100kg = 1800
units/hr
- 25000 units - in 250
1800 units ---in X ml
x = 1800 x 250/25000 =18 mL/hr
An adult male who fell 20 feet from the roof of his home has
multiple injuries, including a right pneumothorax. Chest tubes
were inserted in the emergency department prior to his transfer to
the intensive care unit (ICU). The nurse notes that the suction
control chamber is bubbling at the -10cm H2O mark, which
fluctuation in the water seal, and over the past hour 75 mL of
bright red blood is measured in the collection chamber. Which
intervention should the nurse implement?
, A. Add sterile water to the suction control chamber
B. Give blood from the collection chamber as autotransfusion
C. Manipulate blood in tubing to drain into chamber
D. Increase wall suction to eliminate fluctuation in water seal
A. Add sterile water to the suction control chamber
An adult male was diagnosed with stage IV lung cancer three
weeks ago. His wife approaches the nurse and asks how she will
know that her husband's death is imminent because their two
adult children want to be there when he dies. Which is the best
response by the nurse?
A. Gather information regarding how long it will take for the
children to arrive
B. Explain that the client will start to lose consciousness and the
body systems will slow down
C. Reassure the spouse that the healthcare provider will notify
when to call the children
D. Offer to discuss the client's health status with each of the adult
children
B. Explain that the client will start to lose consciousness and the
body systems will slow down
QUESTIONS WITH VERIFIED
ANSWERS
The nurse assumes care of a postoperative adult client with type
2 diabetes mellitus and learns that the client has a current blood
glucose level of 720 mg/dL. When assessing the client, what is
the priority?
A. Assess for signs of fluid volume deficit
B. Observe wound drainage characteristics
C. Measure the level of acute pain
D. Determine when the client last ate
A. Assess for signs of fluid volume deficit
A male client tells the nurse that he is concerned that he may
have a stomach ulcer, because he is experiencing heartburn and
dull gnawing pain that is relieved when he eats. Which is the best
response by the nurse?
A. Encourage the client to obtain a complete physical exam, since
these symptoms are consistent with an ulcer
,B. Assure the client that his symptoms may only reflect reflux,
since ulcer pain is not relieved with food
C. Instruct the client that these mild symptoms can generally be
controlled with changes in his diet
D. Advise the client that he needs to seek immediate medical
evaluation and treatment of these symptoms
A. Encourage the client to obtain a complete physical exam,
since these symptoms are consistent with an ulcer
A male client with stomach cancer returns to the unit following a
total gastrectomy. He has a nasogastric tube to suction and is
receiving Lactated Ringer's solution at 75 mL/hr IV. One hour after
admission to the unit, the nurse notes 300mL of blood in the
suction canister, the client's heart rate is 155 beats/minute, and
his blood pressure is 78/48 mmHg. In addition to reporting the
findings to the surgeon, which action should the nurse implement
first?
A. Measure and document the client's urinary output
B. Request the client's reserved unit of packed red blood cells
C. Prepare for placement of a central venous catheter
D. Increase the infusion rate of Lactated Ringer's solution
D. Increase the infusion rate of Lactated Ringer's solution
,A heparin infusion is prescribed for a client who weighs 220
pounds. After administering a bolus dose of 80 units/kg, the
nurse calculates the infusion rate for the heparin solution as 18
units/kg/hour. The available solution is Heparin Sodium 25,000
Units in 5% Dextrose Injection 250 mL. The nurse should program
the infusion pump to deliver how many mL/hour?
-1st: calculate the weight = 220/2.2= 100kg
-Then calculate total dose in units = 18units x 100kg = 1800
units/hr
- 25000 units - in 250
1800 units ---in X ml
x = 1800 x 250/25000 =18 mL/hr
An adult male who fell 20 feet from the roof of his home has
multiple injuries, including a right pneumothorax. Chest tubes
were inserted in the emergency department prior to his transfer to
the intensive care unit (ICU). The nurse notes that the suction
control chamber is bubbling at the -10cm H2O mark, which
fluctuation in the water seal, and over the past hour 75 mL of
bright red blood is measured in the collection chamber. Which
intervention should the nurse implement?
, A. Add sterile water to the suction control chamber
B. Give blood from the collection chamber as autotransfusion
C. Manipulate blood in tubing to drain into chamber
D. Increase wall suction to eliminate fluctuation in water seal
A. Add sterile water to the suction control chamber
An adult male was diagnosed with stage IV lung cancer three
weeks ago. His wife approaches the nurse and asks how she will
know that her husband's death is imminent because their two
adult children want to be there when he dies. Which is the best
response by the nurse?
A. Gather information regarding how long it will take for the
children to arrive
B. Explain that the client will start to lose consciousness and the
body systems will slow down
C. Reassure the spouse that the healthcare provider will notify
when to call the children
D. Offer to discuss the client's health status with each of the adult
children
B. Explain that the client will start to lose consciousness and the
body systems will slow down
