HESI RN Exit V2 * QUESTONS AND
ANSWERS
The nnurse nassumes ncare nof na npostoperative nadult nclient nwith ntype n2 ndiabetes nmellitus nand
nlearns nthat nthe nclient nhas na ncurrent nblood nglucose nlevel nof n720 nmg/dL. nWhen nassessing nthe
nclient, nwhat nis nthe npriority?
A. nAssess nfor nsigns nof nfluid nvolume ndeficit
B. nObserve nwound ndrainage ncharacteristics
C. nMeasure nthe nlevel nof nacute npain
D. nDetermine nwhen nthe nclient nlast nate n- nAnswer n- nA. nAssess nfor nsigns nof nfluid nvolume ndeficit
A nmale nclient ntells nthe nnurse nthat nhe nis nconcerned nthat nhe nmay nhave na nstomach nulcer,
nbecause nhe nis nexperiencing nheartburn nand ndull ngnawing npain nthat nis nrelieved nwhen nhe neats.
nWhich nis nthe nbest nresponse nby nthe nnurse?
A. nEncourage nthe nclient nto nobtain na ncomplete nphysical nexam, nsince nthese nsymptoms nare
nconsistent nwith nan nulcer
B. nAssure nthe nclient nthat nhis nsymptoms nmay nonly nreflect nreflux, nsince nulcer npain nis nnot
nrelieved nwith nfood
C. nInstruct nthe nclient nthat nthese nmild nsymptoms ncan ngenerally nbe ncontrolled nwith nchanges nin
nhis ndiet
D. nAdvise nthe nclient nthat nhe nneeds nto nseek nimmediate nmedical nevaluation nand ntreatment nof
nthese nsymptoms n- nAnswer n- nA. nEncourage nthe nclient nto nobtain na ncomplete nphysical nexam,
nsince nthese nsymptoms nare nconsistent nwith nan nulcer
A nmale nclient nwith nstomach ncancer nreturns nto nthe nunit nfollowing na ntotal ngastrectomy. nHe nhas
na nnasogastric ntube nto nsuction nand nis nreceiving nLactated nRinger's nsolution nat n75 nmL/hr nIV. nOne
nhour nafter nadmission nto nthe nunit, nthe nnurse nnotes n300mL nof nblood nin nthe nsuction ncanister,
nthe nclient's nheart nrate nis n155 nbeats/minute, nand nhis nblood npressure nis n78/48 nmmHg. nIn
naddition nto nreporting nthe nfindings nto nthe nsurgeon, nwhich naction nshould nthe nnurse nimplement
nfirst?
,A. nMeasure nand ndocument nthe nclient's nurinary noutput
B. nRequest nthe nclient's nreserved nunit nof npacked nred nblood ncells
C. nPrepare nfor nplacement nof na ncentral nvenous ncatheter
D. nIncrease nthe ninfusion nrate nof nLactated nRinger's nsolution n- nAnswer n- nD. nIncrease nthe ninfusion
nrate nof nLactated nRinger's nsolution
A nheparin ninfusion nis nprescribed nfor na nclient nwho nweighs n220 npounds. nAfter nadministering na
nbolus ndose nof n80 nunits/kg, nthe nnurse ncalculates nthe ninfusion nrate nfor nthe nheparin nsolution nas
n18 nunits/kg/hour. nThe navailable nsolution nis nHeparin nSodium n25,000 nUnits nin n5% nDextrose
nInjection n250 nmL. nThe nnurse nshould nprogram nthe ninfusion npump nto ndeliver nhow nmany
nmL/hour? n- nAnswer n- n-1st: ncalculate nthe nweight n= n220/2.2= n100kg
-Then ncalculate ntotal ndose nin nunits n= n18units nx n100kg n= n1800 nunits/hr
- n25000 nunits n- nin n250
n1800 nunits n---in nX nml
x n= n1800 nx n250/25000 n=18 nmL/hr
An nadult nmale nwho nfell n20 nfeet nfrom nthe nroof nof nhis nhome nhas nmultiple ninjuries, nincluding na
nright npneumothorax. nChest ntubes nwere ninserted nin nthe nemergency ndepartment nprior nto nhis
ntransfer nto nthe nintensive ncare nunit n(ICU). nThe nnurse nnotes nthat nthe nsuction ncontrol nchamber
nis nbubbling nat nthe n-10cm nH2O nmark, nwhich nfluctuation nin nthe nwater nseal, nand nover nthe npast
nhour n75 nmL nof nbright nred nblood nis nmeasured nin nthe ncollection nchamber. nWhich nintervention
nshould nthe nnurse nimplement?
A. nAdd nsterile nwater nto nthe nsuction ncontrol nchamber
B. nGive nblood nfrom nthe ncollection nchamber nas nautotransfusion
C. nManipulate nblood nin ntubing nto ndrain ninto nchamber
D. nIncrease nwall nsuction nto neliminate nfluctuation nin nwater nseal n- nAnswer n- nA. nAdd nsterile nwater
nto nthe nsuction ncontrol nchamber
An nadult nmale nwas ndiagnosed nwith nstage nIV nlung ncancer nthree nweeks nago. nHis nwife
napproaches nthe nnurse nand nasks nhow nshe nwill nknow nthat nher nhusband's ndeath nis nimminent
nbecause ntheir ntwo nadult nchildren nwant nto nbe nthere nwhen nhe ndies. nWhich nis nthe nbest
nresponse nby nthe nnurse? n
A. nGather ninformation nregarding nhow nlong nit nwill ntake nfor nthe nchildren nto narrive
,B. nExplain nthat nthe nclient nwill nstart nto nlose nconsciousness nand nthe nbody nsystems nwill nslow
ndown
C. nReassure nthe nspouse nthat nthe nhealthcare nprovider nwill nnotify nwhen nto ncall nthe nchildren n
D. nOffer nto ndiscuss nthe nclient's nhealth nstatus nwith neach nof nthe nadult nchildren n- nAnswer n- nB.
nExplain nthat nthe nclient nwill nstart nto nlose nconsciousness nand nthe nbody nsystems nwill nslow ndown
The ncharge nnurse nof na ncritical ncare nunit nis ninformed nat nthe nbeginning nof nthe nshift nthat nless
nthan nthe noptimal nnumber nof nregistered nnurses nwill nbe nworking nthat nshift. nIn nplanning
nassignments, nwhich nclient nshould nreceive nthe nmost ncare nhours nby na nregistered nnurse n(RN)?
A. nA n48-year-old nmarathon nrunner nwith na ncentral nvenous ncatheter nwho nis nexperiencing nnausea
nand nvomiting ndue nto nelectrolyte ndisturbance nfollowing na nrace
B. nA n34-year-old nadmitted ntoday nafter nan nemergency nappendectomy nwho nhas na nperipheral
nintravenous ncatheter nand na nFoley ncatheter
C. nA n63-year-old nchain nsmoker nadmitted nwith nchronic nbronchitis nwho nis nreceiving noxygen nvia
nnasal ncannula nand nhas na nsaline-locked nperipheral nintravenous ncatheter
D. nAn n82-year-old nclient nwith nAlzheimer's ndisease nand na nnewly-fractured nfemur nwho nhas na
nFoley ncatheter nand nsoft nwrist nrestraints napplied n- nAnswer n- nD. nAn n82-year-old nclient nwith
nAlzheimer's ndisease nand na nnewly-fractured nfemur nwho nhas na nFoley ncatheter nand nsoft nwrist
nrestraints napplied
The nnurse nis npreparing na ndose nof n60 nmcg nof nteriparatide. nThe nmedication nis nlabeled n"750
nmcg/2.4mL". nHow nmany nmL nshould nthe nnurse nadminister? nRound nto nnearest ntenth. n- nAnswer n-
n0.2 nmL
In ncaring nfor na nclient nwith nCushing's nSyndrome, nwhich nserum nlaboratory nvalue nis nmost
nimportant nfor nthe nnurse nto nmonitor?
A. nCreatinine
B. nLactate
C. nGlucose
D. nHemoglobin n- nAnswer n- nC. nGlucose
A nclient nwho nreceived nhemodialysis nyesterday nis nexperiencing na nblood npressure nof n200/100
nmmHg, nheart nrate n110 nbeats/minute, nand nrespiratory nrate n36 nbreaths/minute. nThe nclient nis
, nmanifesting nshortness nof nbreath, nbilateral n2+ npedal nedema, nand nan noxygen nsaturation non nroom
nair nof n89%. nWhich naction nshould nthe nnurse ntake nfirst?
A. nElevate nthe nfoot nof nthe nbed
B. nRestrict nthe nclient's nfluids
C. nBegin nsupplemental noxygen
D. nPrepare nclient nfor nhemodialysis n- nAnswer n- nC. nBegin nsupplemental noxygen
When ncaring nfor na nclient nwith nfull nthickness nburns nto nboth nlower nextremities, nwhich
nassessment nfindings nwarrant nimmediate nintervention? nSelect nall nthat napply
A. nSloughing ntissue naround nwound nedges
B. nComplaint nof nincreased npain nand npressure
C. nChange nin nthe nquality nof nthe nperipheral npulses
D. nLoss nof nsensation nto nthe nleft nlower nextremity
E. nWeeping nserosanguineous nfluid nfrom nwounds n- nAnswer n- nB. nComplaint nof nincreased npain
nand npressure
C. nChange nin nthe nquality nof nthe nperipheral npulses
D. nLoss nof nsensation nto nthe nleft nlower nextremity
An nolder nclient nis nadmitted nwith nfluid nvolume ndeficit nand ndehydration. nWhich nassessment
nfinding nis nthe nbest nindicator nof nhydration nthat nthe nnurse nshould nreport nto nthe nhealthcare
nprovider?
A. nUrine nspecific ngravity nis n1.040
B. nSystolic nblood npressure ndecreases n10 npoints nwhen nstanding
C. nThe nclient ndenies nbeing nthirsty
D. nSkin ntenting noccurs nwhen nthe nclient's nforearm nis npinched n- nAnswer n- nD. nSkin ntenting noccurs
nwhen nthe nclient's nforearm nis npinched
The nhealthcare nprovider nprescribes nmethylergonovine nmaleate nfor na npostpartum nclient nwith
nuterine natony. nWhat nfinding nshould nindicate nto nthe nnurse nto nwithhold nthe nnext ndose nof nthe
nmedication?
A. nDifficulty nlocating nthe nuterine nfundus
ANSWERS
The nnurse nassumes ncare nof na npostoperative nadult nclient nwith ntype n2 ndiabetes nmellitus nand
nlearns nthat nthe nclient nhas na ncurrent nblood nglucose nlevel nof n720 nmg/dL. nWhen nassessing nthe
nclient, nwhat nis nthe npriority?
A. nAssess nfor nsigns nof nfluid nvolume ndeficit
B. nObserve nwound ndrainage ncharacteristics
C. nMeasure nthe nlevel nof nacute npain
D. nDetermine nwhen nthe nclient nlast nate n- nAnswer n- nA. nAssess nfor nsigns nof nfluid nvolume ndeficit
A nmale nclient ntells nthe nnurse nthat nhe nis nconcerned nthat nhe nmay nhave na nstomach nulcer,
nbecause nhe nis nexperiencing nheartburn nand ndull ngnawing npain nthat nis nrelieved nwhen nhe neats.
nWhich nis nthe nbest nresponse nby nthe nnurse?
A. nEncourage nthe nclient nto nobtain na ncomplete nphysical nexam, nsince nthese nsymptoms nare
nconsistent nwith nan nulcer
B. nAssure nthe nclient nthat nhis nsymptoms nmay nonly nreflect nreflux, nsince nulcer npain nis nnot
nrelieved nwith nfood
C. nInstruct nthe nclient nthat nthese nmild nsymptoms ncan ngenerally nbe ncontrolled nwith nchanges nin
nhis ndiet
D. nAdvise nthe nclient nthat nhe nneeds nto nseek nimmediate nmedical nevaluation nand ntreatment nof
nthese nsymptoms n- nAnswer n- nA. nEncourage nthe nclient nto nobtain na ncomplete nphysical nexam,
nsince nthese nsymptoms nare nconsistent nwith nan nulcer
A nmale nclient nwith nstomach ncancer nreturns nto nthe nunit nfollowing na ntotal ngastrectomy. nHe nhas
na nnasogastric ntube nto nsuction nand nis nreceiving nLactated nRinger's nsolution nat n75 nmL/hr nIV. nOne
nhour nafter nadmission nto nthe nunit, nthe nnurse nnotes n300mL nof nblood nin nthe nsuction ncanister,
nthe nclient's nheart nrate nis n155 nbeats/minute, nand nhis nblood npressure nis n78/48 nmmHg. nIn
naddition nto nreporting nthe nfindings nto nthe nsurgeon, nwhich naction nshould nthe nnurse nimplement
nfirst?
,A. nMeasure nand ndocument nthe nclient's nurinary noutput
B. nRequest nthe nclient's nreserved nunit nof npacked nred nblood ncells
C. nPrepare nfor nplacement nof na ncentral nvenous ncatheter
D. nIncrease nthe ninfusion nrate nof nLactated nRinger's nsolution n- nAnswer n- nD. nIncrease nthe ninfusion
nrate nof nLactated nRinger's nsolution
A nheparin ninfusion nis nprescribed nfor na nclient nwho nweighs n220 npounds. nAfter nadministering na
nbolus ndose nof n80 nunits/kg, nthe nnurse ncalculates nthe ninfusion nrate nfor nthe nheparin nsolution nas
n18 nunits/kg/hour. nThe navailable nsolution nis nHeparin nSodium n25,000 nUnits nin n5% nDextrose
nInjection n250 nmL. nThe nnurse nshould nprogram nthe ninfusion npump nto ndeliver nhow nmany
nmL/hour? n- nAnswer n- n-1st: ncalculate nthe nweight n= n220/2.2= n100kg
-Then ncalculate ntotal ndose nin nunits n= n18units nx n100kg n= n1800 nunits/hr
- n25000 nunits n- nin n250
n1800 nunits n---in nX nml
x n= n1800 nx n250/25000 n=18 nmL/hr
An nadult nmale nwho nfell n20 nfeet nfrom nthe nroof nof nhis nhome nhas nmultiple ninjuries, nincluding na
nright npneumothorax. nChest ntubes nwere ninserted nin nthe nemergency ndepartment nprior nto nhis
ntransfer nto nthe nintensive ncare nunit n(ICU). nThe nnurse nnotes nthat nthe nsuction ncontrol nchamber
nis nbubbling nat nthe n-10cm nH2O nmark, nwhich nfluctuation nin nthe nwater nseal, nand nover nthe npast
nhour n75 nmL nof nbright nred nblood nis nmeasured nin nthe ncollection nchamber. nWhich nintervention
nshould nthe nnurse nimplement?
A. nAdd nsterile nwater nto nthe nsuction ncontrol nchamber
B. nGive nblood nfrom nthe ncollection nchamber nas nautotransfusion
C. nManipulate nblood nin ntubing nto ndrain ninto nchamber
D. nIncrease nwall nsuction nto neliminate nfluctuation nin nwater nseal n- nAnswer n- nA. nAdd nsterile nwater
nto nthe nsuction ncontrol nchamber
An nadult nmale nwas ndiagnosed nwith nstage nIV nlung ncancer nthree nweeks nago. nHis nwife
napproaches nthe nnurse nand nasks nhow nshe nwill nknow nthat nher nhusband's ndeath nis nimminent
nbecause ntheir ntwo nadult nchildren nwant nto nbe nthere nwhen nhe ndies. nWhich nis nthe nbest
nresponse nby nthe nnurse? n
A. nGather ninformation nregarding nhow nlong nit nwill ntake nfor nthe nchildren nto narrive
,B. nExplain nthat nthe nclient nwill nstart nto nlose nconsciousness nand nthe nbody nsystems nwill nslow
ndown
C. nReassure nthe nspouse nthat nthe nhealthcare nprovider nwill nnotify nwhen nto ncall nthe nchildren n
D. nOffer nto ndiscuss nthe nclient's nhealth nstatus nwith neach nof nthe nadult nchildren n- nAnswer n- nB.
nExplain nthat nthe nclient nwill nstart nto nlose nconsciousness nand nthe nbody nsystems nwill nslow ndown
The ncharge nnurse nof na ncritical ncare nunit nis ninformed nat nthe nbeginning nof nthe nshift nthat nless
nthan nthe noptimal nnumber nof nregistered nnurses nwill nbe nworking nthat nshift. nIn nplanning
nassignments, nwhich nclient nshould nreceive nthe nmost ncare nhours nby na nregistered nnurse n(RN)?
A. nA n48-year-old nmarathon nrunner nwith na ncentral nvenous ncatheter nwho nis nexperiencing nnausea
nand nvomiting ndue nto nelectrolyte ndisturbance nfollowing na nrace
B. nA n34-year-old nadmitted ntoday nafter nan nemergency nappendectomy nwho nhas na nperipheral
nintravenous ncatheter nand na nFoley ncatheter
C. nA n63-year-old nchain nsmoker nadmitted nwith nchronic nbronchitis nwho nis nreceiving noxygen nvia
nnasal ncannula nand nhas na nsaline-locked nperipheral nintravenous ncatheter
D. nAn n82-year-old nclient nwith nAlzheimer's ndisease nand na nnewly-fractured nfemur nwho nhas na
nFoley ncatheter nand nsoft nwrist nrestraints napplied n- nAnswer n- nD. nAn n82-year-old nclient nwith
nAlzheimer's ndisease nand na nnewly-fractured nfemur nwho nhas na nFoley ncatheter nand nsoft nwrist
nrestraints napplied
The nnurse nis npreparing na ndose nof n60 nmcg nof nteriparatide. nThe nmedication nis nlabeled n"750
nmcg/2.4mL". nHow nmany nmL nshould nthe nnurse nadminister? nRound nto nnearest ntenth. n- nAnswer n-
n0.2 nmL
In ncaring nfor na nclient nwith nCushing's nSyndrome, nwhich nserum nlaboratory nvalue nis nmost
nimportant nfor nthe nnurse nto nmonitor?
A. nCreatinine
B. nLactate
C. nGlucose
D. nHemoglobin n- nAnswer n- nC. nGlucose
A nclient nwho nreceived nhemodialysis nyesterday nis nexperiencing na nblood npressure nof n200/100
nmmHg, nheart nrate n110 nbeats/minute, nand nrespiratory nrate n36 nbreaths/minute. nThe nclient nis
, nmanifesting nshortness nof nbreath, nbilateral n2+ npedal nedema, nand nan noxygen nsaturation non nroom
nair nof n89%. nWhich naction nshould nthe nnurse ntake nfirst?
A. nElevate nthe nfoot nof nthe nbed
B. nRestrict nthe nclient's nfluids
C. nBegin nsupplemental noxygen
D. nPrepare nclient nfor nhemodialysis n- nAnswer n- nC. nBegin nsupplemental noxygen
When ncaring nfor na nclient nwith nfull nthickness nburns nto nboth nlower nextremities, nwhich
nassessment nfindings nwarrant nimmediate nintervention? nSelect nall nthat napply
A. nSloughing ntissue naround nwound nedges
B. nComplaint nof nincreased npain nand npressure
C. nChange nin nthe nquality nof nthe nperipheral npulses
D. nLoss nof nsensation nto nthe nleft nlower nextremity
E. nWeeping nserosanguineous nfluid nfrom nwounds n- nAnswer n- nB. nComplaint nof nincreased npain
nand npressure
C. nChange nin nthe nquality nof nthe nperipheral npulses
D. nLoss nof nsensation nto nthe nleft nlower nextremity
An nolder nclient nis nadmitted nwith nfluid nvolume ndeficit nand ndehydration. nWhich nassessment
nfinding nis nthe nbest nindicator nof nhydration nthat nthe nnurse nshould nreport nto nthe nhealthcare
nprovider?
A. nUrine nspecific ngravity nis n1.040
B. nSystolic nblood npressure ndecreases n10 npoints nwhen nstanding
C. nThe nclient ndenies nbeing nthirsty
D. nSkin ntenting noccurs nwhen nthe nclient's nforearm nis npinched n- nAnswer n- nD. nSkin ntenting noccurs
nwhen nthe nclient's nforearm nis npinched
The nhealthcare nprovider nprescribes nmethylergonovine nmaleate nfor na npostpartum nclient nwith
nuterine natony. nWhat nfinding nshould nindicate nto nthe nnurse nto nwithhold nthe nnext ndose nof nthe
nmedication?
A. nDifficulty nlocating nthe nuterine nfundus
