RN EXIT HESI EXAM V5 Exam
Questions 2025
After placing a 36-week gestation newborn in and isolette and
drying the infant with several blankets, what should the nurse
implement next?
a. Administer the vitamin K injection
b. Remove the wet blankets and linens from the isolette
c. Place erythromycin ophthalmic ointment in both eyes
d. Open the isolate door to assess the infants' vital signs
c. Place erythromycin ophthalmic ointment in both eyes
A client in the third trimester of pregnancy complaints of frequent
nasal stuffiness 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?
A. Ask a nurse with more experience to validate the costal angle
finding
B. Ask the health care provider to evaluate the client's respiratory
status
C. Examine the client for signs of tissue and anoxia, such as pallor
D. Record the respiratory finding in the client's record as normal
C. Examine the client for signs of tissue and anoxia, such as pallor
A terminally ill male hospice client who is at home is showing
decreased awareness of his surroundings. His appetite is poor, and
he often uses 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?
A. Ask family to remain nearby, but in another room
B. Encourage family to speak often with the client
C. Teach family how to assist the client to a wheelchair
D. Instruct family to offer client only soft bland foods
C. Teach family how to assist the client to a wheelchair
A woman was admitted yesterday afternoon with severe abdominal
pain. Her pregnancy tests and ultrasounds were negative, so an
,exploratory laparotomy was completed during the night. When
coffee ground material is observed in the drainage from the nasal
gastric tube, which intervention should the nurse implement?
a. Verify correct placement of the nasogastric tube
b. Perform gastroccult test on the nasogastric drainage
c. Listen for evidence of diminished bowel sounds
d. Irrigate the nasogastric tube with water until clear
a. Verify correct placement of the nasogastric tube
The nurse is reviewing the laboratory values for a client with acute
pancreatitis who reports that the abdominal pain is not as severe as
it was on admission. Which laboratory test should the nurse review
to evaluate the client's clinical recovery?
a. Lipase
b. Creatinine
c. Bilirubin
d. Glucose
a. 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?
a. Determine the client's vital signs
b. Monitor urinary output hourly
c. Notify the surgeon immediately
d. Assess the client's level of pain
b. Monitor urinary output hourly
The nurse is reviewing the recommended preventative care for
clients with asthma, chronic bronchitis, and emphysema. Which
healthcare measure is most important for the nurse to recommend
to these clients?
a. Ensure supplemental oxygen and respiratory medications are
available at all times
b. Use nasal or cough tissues followed by hand washing at all times
c. Get annual flu and pneumococcal vaccine polyvalent vaccines
d. Avoid large crowded areas during the colder months of the year
d. Avoid large crowded areas during the colder months of the year
,A mother of a one-month-old infant calls the clinic to report that the
back of her infant's head is flat. How should the nurse respond?
a. Position the infant on the stomach occasionally when awake and
active
b. Turn the infant on the left side braced against the crib when
sleeping
c. Prop the infant in a sitting position with a cushion when not
sleeping
d. Place a small pillow under the infants head while lying on the
back
a. Position the infant on the stomach occasionally when awake and active
A woman is brought to the labor and delivery unit after delivering a
term infant and the placenta in the hospital parking lot 10 minutes
ago. Which action should the nurse perform first?
a. Inspect the perineum for lacerations
b. Collect specimen for hemoglobin and hematocrit
c. Massage the fundus and give oxytocic agent
d. Place the infant to breast for bonding
c. Massage the fundus and give oxytocic agent
A client has a new prescription for the maximum recommended
dosage of piperacillin/tazobactam for nosocomial pneumonia. The
nurse should report which laboratory finding to the health care
provider before administering the prescribed dose?
a. Elevated white blood cell count
b. Presence of gram-positive bacteria in the sputum
c. Decrease creatinine clearance
d. Elevated cholesterol and lipoproteins
b. Presence of gram-positive bacteria in the sputum
A client who is admitted with diabetic ketoacidosis is demonstrating
Kussmaul breathing and has a severe headache along with nausea.
Her arterial blood gases are: ph 7.50; paco2 30 mmhg; HCO3 24
meq/L. Which assessment finding warrants immediate intervention
by the nurse?
a. Muscle stiffness
b. Abdominal pain
c. Mental stupor
d. Fruity breath
d. Fruity breath
, When performing postural drainage on a client with chronic
obstructive pulmonary disease, which approach should the nurse
use?
a. Explain that the client may be placed in five positions
b. Instruct the client to breathe shallow and fast
c. Obtain arterial blood gases prior to the procedure
d. Perform the drainage immediately after meals
a. 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 health care provider knows the client has a good
prognosis and refuses to write a "do not resuscitate" (DNR)
prescription. Which action should the nurse take?
A. Initiate an Ethics Committee review of the case
B. Place a DNR bracelet on the client's arm
C. Ensure resuscitation equipment is available
D. Ask the family to review options with the client
A. Initiate an Ethics Committee review of the case
In observing a client's face, which assessment finding requires the
most immediate intervention by the nurse?
a. Cornea are jaundiced
b. Oral mucosa is cyanotic
c. Face is flushed and diaphoretic
d. Eyelids are matted and crusted
b. Oral mucosa is cyanotic
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?
a. Ask the client to describe recent alcohol use
b. Keep the clients feet elevated when in bed
c. Assess the clients muscle strength and tone
d. Complete a thorough neurological assessment
d. 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
Questions 2025
After placing a 36-week gestation newborn in and isolette and
drying the infant with several blankets, what should the nurse
implement next?
a. Administer the vitamin K injection
b. Remove the wet blankets and linens from the isolette
c. Place erythromycin ophthalmic ointment in both eyes
d. Open the isolate door to assess the infants' vital signs
c. Place erythromycin ophthalmic ointment in both eyes
A client in the third trimester of pregnancy complaints of frequent
nasal stuffiness 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?
A. Ask a nurse with more experience to validate the costal angle
finding
B. Ask the health care provider to evaluate the client's respiratory
status
C. Examine the client for signs of tissue and anoxia, such as pallor
D. Record the respiratory finding in the client's record as normal
C. Examine the client for signs of tissue and anoxia, such as pallor
A terminally ill male hospice client who is at home is showing
decreased awareness of his surroundings. His appetite is poor, and
he often uses 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?
A. Ask family to remain nearby, but in another room
B. Encourage family to speak often with the client
C. Teach family how to assist the client to a wheelchair
D. Instruct family to offer client only soft bland foods
C. Teach family how to assist the client to a wheelchair
A woman was admitted yesterday afternoon with severe abdominal
pain. Her pregnancy tests and ultrasounds were negative, so an
,exploratory laparotomy was completed during the night. When
coffee ground material is observed in the drainage from the nasal
gastric tube, which intervention should the nurse implement?
a. Verify correct placement of the nasogastric tube
b. Perform gastroccult test on the nasogastric drainage
c. Listen for evidence of diminished bowel sounds
d. Irrigate the nasogastric tube with water until clear
a. Verify correct placement of the nasogastric tube
The nurse is reviewing the laboratory values for a client with acute
pancreatitis who reports that the abdominal pain is not as severe as
it was on admission. Which laboratory test should the nurse review
to evaluate the client's clinical recovery?
a. Lipase
b. Creatinine
c. Bilirubin
d. Glucose
a. 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?
a. Determine the client's vital signs
b. Monitor urinary output hourly
c. Notify the surgeon immediately
d. Assess the client's level of pain
b. Monitor urinary output hourly
The nurse is reviewing the recommended preventative care for
clients with asthma, chronic bronchitis, and emphysema. Which
healthcare measure is most important for the nurse to recommend
to these clients?
a. Ensure supplemental oxygen and respiratory medications are
available at all times
b. Use nasal or cough tissues followed by hand washing at all times
c. Get annual flu and pneumococcal vaccine polyvalent vaccines
d. Avoid large crowded areas during the colder months of the year
d. Avoid large crowded areas during the colder months of the year
,A mother of a one-month-old infant calls the clinic to report that the
back of her infant's head is flat. How should the nurse respond?
a. Position the infant on the stomach occasionally when awake and
active
b. Turn the infant on the left side braced against the crib when
sleeping
c. Prop the infant in a sitting position with a cushion when not
sleeping
d. Place a small pillow under the infants head while lying on the
back
a. Position the infant on the stomach occasionally when awake and active
A woman is brought to the labor and delivery unit after delivering a
term infant and the placenta in the hospital parking lot 10 minutes
ago. Which action should the nurse perform first?
a. Inspect the perineum for lacerations
b. Collect specimen for hemoglobin and hematocrit
c. Massage the fundus and give oxytocic agent
d. Place the infant to breast for bonding
c. Massage the fundus and give oxytocic agent
A client has a new prescription for the maximum recommended
dosage of piperacillin/tazobactam for nosocomial pneumonia. The
nurse should report which laboratory finding to the health care
provider before administering the prescribed dose?
a. Elevated white blood cell count
b. Presence of gram-positive bacteria in the sputum
c. Decrease creatinine clearance
d. Elevated cholesterol and lipoproteins
b. Presence of gram-positive bacteria in the sputum
A client who is admitted with diabetic ketoacidosis is demonstrating
Kussmaul breathing and has a severe headache along with nausea.
Her arterial blood gases are: ph 7.50; paco2 30 mmhg; HCO3 24
meq/L. Which assessment finding warrants immediate intervention
by the nurse?
a. Muscle stiffness
b. Abdominal pain
c. Mental stupor
d. Fruity breath
d. Fruity breath
, When performing postural drainage on a client with chronic
obstructive pulmonary disease, which approach should the nurse
use?
a. Explain that the client may be placed in five positions
b. Instruct the client to breathe shallow and fast
c. Obtain arterial blood gases prior to the procedure
d. Perform the drainage immediately after meals
a. 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 health care provider knows the client has a good
prognosis and refuses to write a "do not resuscitate" (DNR)
prescription. Which action should the nurse take?
A. Initiate an Ethics Committee review of the case
B. Place a DNR bracelet on the client's arm
C. Ensure resuscitation equipment is available
D. Ask the family to review options with the client
A. Initiate an Ethics Committee review of the case
In observing a client's face, which assessment finding requires the
most immediate intervention by the nurse?
a. Cornea are jaundiced
b. Oral mucosa is cyanotic
c. Face is flushed and diaphoretic
d. Eyelids are matted and crusted
b. Oral mucosa is cyanotic
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?
a. Ask the client to describe recent alcohol use
b. Keep the clients feet elevated when in bed
c. Assess the clients muscle strength and tone
d. Complete a thorough neurological assessment
d. 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
