HESI RN EXIT V2 EXAM
2025
,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 - Precise Answer ✔✔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 - Precise Answer ✔✔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 - Precise
Answer ✔✔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? - Precise Answer ✔✔-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 - Precise
Answer ✔✔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 - Precise Answer ✔✔B. Explain that the client will start to lose
consciousness and the body systems will slow down
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 a registered nurse (RN)?
2025
,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 - Precise Answer ✔✔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 - Precise Answer ✔✔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 - Precise
Answer ✔✔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? - Precise Answer ✔✔-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 - Precise
Answer ✔✔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 - Precise Answer ✔✔B. Explain that the client will start to lose
consciousness and the body systems will slow down
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 a registered nurse (RN)?
