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Hesi Exit Rn V2 Exam Newest 2025/26
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The nurse assumes care of a postoperative adult client with type 2 diab
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etes mellitus and learns that the client has a current blood glucose level
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of 720 mg/dL. When assessing the client, what is the priority?
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A. Assess for signs of fluid volume deficit
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B. Observe wound drainage characteristics
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C. Measure the level of acute pain
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D. Determine when the client last ate -
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..........ANSWER.......A. Assess for signs of fluid volume deficit
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A male client tells the nurse that he is concerned that he may have a sto
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mach ulcer, because he is experiencing heartburn and dull gnawing pai
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n that is relieved when he eats. Which is the best response by the nurse
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?
A. Encourage the client to obtain a complete physical exam, since thes
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e symptoms are consistent with an ulcer
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B. Assure the client that his symptoms may only reflect reflux, since ulc
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er pain is not relieved with food
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C. Instruct the client that these mild symptoms can generally be contro
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lled with changes in his diet
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D. Advise the client that he needs to seek immediate medical evaluatio
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n and treatment of these symptoms -
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..........ANSWER.......A. Encourage the client to obtain a complete physi
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cal exam, since these symptoms are consistent with an ulcer
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A male client with stomach cancer returns to the unit following a total
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gastrectomy. He has a nasogastric tube to suction and is receiving Lact v v v v v v v v v v v
ated Ringer's solution at 75 mL/hr IV. One hour after admission to the u
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nit, the nurse notes 300mL of blood in the suction canister, the client's
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heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. I
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n addition to reporting the findings to the surgeon, which action shoul
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d the nurse implement first?
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A. Measure and document the client's urinary output
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B. Request the client's reserved unit of packed red blood cells
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C. Prepare for placement of a central venous catheter
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D. Increase the infusion rate of Lactated Ringer's solution -
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..........ANSWER.......D. Increase the infusion rate of Lactated Ringer's s
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olution
A heparin infusion is prescribed for a client who weighs 220 pounds. Aft
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er administering a bolus dose of 80 units/kg, the nurse calculates the in
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fusion rate for the heparin solution as 18 units/kg/hour. The available so
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lution is Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL.
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The nurse should program the infusion pump to deliver how many mL/
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hour? - ..........ANSWER.......-1st: calculate the weight = 220/2.2= 100kg
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-Then calculate total dose in units = 18units x 100kg = 1800 units/hr
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- 25000 units - in 250
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1800 units ---in X ml
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x = 1800 x 250/25000 =18 mL/hr
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An adult male who fell 20 feet from the roof of his home has multiple inj
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uries, including a right pneumothorax. Chest tubes were inserted in th
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e emergency department prior to his transfer to the intensive care unit
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(ICU). The nurse notes that the suction control chamber is bubbling at t
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he - v