HESI RN EXIT EXAM V2 2025 RATED A

HESI RN EXIT EXAM V2 2025 RATED A 1. 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 750 mg/dL. When assessing the client, what is the priority? a. Assess for signs of fluids volume deficit 2. A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a 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 3. 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/hour IV. One hour after admission to the unit, the nurse notes 300mL of blood in the suction canister, the client’s heart rate is 155bpm, 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. Increase the infusion rate of Lactated Ringer’s solution 4. 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 at 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? (Enter numeric value only. If rounding is required, round to the nearest whole number) a. 18 Rationale: 1st we calculate the weight; 220/2.2 = 100kg Then we calculate total dose in units; dose = 18 units x 100 = 1800 units/hr We use the reference to get the final answer 25,000units --- in 250mL 1800 units --- in X mL X = 1800 * 250/25,000 = 18 5. An adult male who fell 20 feet from her 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 -10 cm H2O mark, with 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 6. 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. Explain that the client will start to lose consciousness and the body systems will slow down 7. The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by the registered nurse (RN)? a. An 82-year-old client with Alzheimer’s disease and a newly fractured femur who has a Foley catheter and soft wrist restraints applied 8. The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled “750 mcg/2.4mL.” How many mL should the nurse administer? (if rounding is required, round to the nearest tenth) a. 0.2 9. In caring for a client with Cushing’s syndrome, which serum laboratory value is most important for the nurse to monitor? a. Glucose 10. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110bpm, and respiratory rate 36 bpm. The client manifested shortness of breath, bilateral 2+ edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first? a. Begin supplement oxygen