HESI Term 2 Exit Questions and
Answers | Latest Version | 2025/2026 |
Correct & Verified
A patient develops shortness of breath during ambulation. What should the nurse do first?
A. Continue ambulation to build tolerance
✔✔B. Assist the patient to sit or lie down and assess respiratory status
C. Call family to assist
D. Administer oxygen without assessment
A patient reports severe pain after surgery. Which action is most appropriate?
A. Tell the patient to wait until the next scheduled dose
✔✔B. Assess the pain and administer prescribed analgesics as needed
C. Suggest alternative therapy only
D. Ignore the complaint if vital signs are normal
A client has a new prescription for a diuretic. What is the priority assessment before
administration?
A. Blood glucose level
1
,✔✔B. Serum potassium level
C. Pulse oximetry
D. Temperature
A patient reports dizziness upon standing. What is the most appropriate initial intervention?
✔✔A. Assist the patient to sit or lie down and assess vital signs
B. Encourage the patient to walk slowly
C. Administer IV fluids immediately
D. Ignore if dizziness resolves spontaneously
A nurse notes redness and warmth around a patient’s IV site. What should be the first action?
A. Massage the area
✔✔B. Stop the IV and assess for infiltration or infection
C. Flush the IV
D. Apply a warm compress only
A client is scheduled for surgery and asks why fasting is required. What is the best response?
A. Fasting helps the provider see the organs clearly
2
,B. It prevents nausea after surgery
✔✔C. Fasting reduces the risk of aspiration during anesthesia
D. It improves healing
A patient’s oxygen saturation drops to 88%. What is the nurse’s priority action?
A. Reassess in 10 minutes
B. Encourage deep breathing only
✔✔C. Apply supplemental oxygen and assess respiratory status
D. Document and continue monitoring
A patient develops a rash after receiving penicillin. What is the most appropriate response?
A. Ignore and continue treatment
✔✔B. Stop the medication and notify the provider
C. Apply lotion to the rash
D. Document and observe
A patient is refusing medication due to fear of side effects. What should the nurse do first?
A. Administer the medication anyway
3
, B. Ask the patient to sign a refusal form only
✔✔C. Explain the purpose, benefits, and risks of the medication
D. Wait until the patient changes their mind
A client with diabetes reports blood sugar of 320 mg/dL. What is the nurse’s initial action?
A. Administer insulin without further assessment
✔✔B. Assess for hyperglycemia symptoms and notify the provider
C. Encourage the patient to drink water only
D. Document and recheck later
A child presents with a high fever and seizure activity. What is the priority nursing action?
✔✔A. Ensure the child’s safety and maintain airway during seizure
B. Administer antipyretic immediately
C. Call family to observe
D. Document seizure
A postoperative patient reports sudden chest pain radiating to the left arm. What is the first
action?
4
Answers | Latest Version | 2025/2026 |
Correct & Verified
A patient develops shortness of breath during ambulation. What should the nurse do first?
A. Continue ambulation to build tolerance
✔✔B. Assist the patient to sit or lie down and assess respiratory status
C. Call family to assist
D. Administer oxygen without assessment
A patient reports severe pain after surgery. Which action is most appropriate?
A. Tell the patient to wait until the next scheduled dose
✔✔B. Assess the pain and administer prescribed analgesics as needed
C. Suggest alternative therapy only
D. Ignore the complaint if vital signs are normal
A client has a new prescription for a diuretic. What is the priority assessment before
administration?
A. Blood glucose level
1
,✔✔B. Serum potassium level
C. Pulse oximetry
D. Temperature
A patient reports dizziness upon standing. What is the most appropriate initial intervention?
✔✔A. Assist the patient to sit or lie down and assess vital signs
B. Encourage the patient to walk slowly
C. Administer IV fluids immediately
D. Ignore if dizziness resolves spontaneously
A nurse notes redness and warmth around a patient’s IV site. What should be the first action?
A. Massage the area
✔✔B. Stop the IV and assess for infiltration or infection
C. Flush the IV
D. Apply a warm compress only
A client is scheduled for surgery and asks why fasting is required. What is the best response?
A. Fasting helps the provider see the organs clearly
2
,B. It prevents nausea after surgery
✔✔C. Fasting reduces the risk of aspiration during anesthesia
D. It improves healing
A patient’s oxygen saturation drops to 88%. What is the nurse’s priority action?
A. Reassess in 10 minutes
B. Encourage deep breathing only
✔✔C. Apply supplemental oxygen and assess respiratory status
D. Document and continue monitoring
A patient develops a rash after receiving penicillin. What is the most appropriate response?
A. Ignore and continue treatment
✔✔B. Stop the medication and notify the provider
C. Apply lotion to the rash
D. Document and observe
A patient is refusing medication due to fear of side effects. What should the nurse do first?
A. Administer the medication anyway
3
, B. Ask the patient to sign a refusal form only
✔✔C. Explain the purpose, benefits, and risks of the medication
D. Wait until the patient changes their mind
A client with diabetes reports blood sugar of 320 mg/dL. What is the nurse’s initial action?
A. Administer insulin without further assessment
✔✔B. Assess for hyperglycemia symptoms and notify the provider
C. Encourage the patient to drink water only
D. Document and recheck later
A child presents with a high fever and seizure activity. What is the priority nursing action?
✔✔A. Ensure the child’s safety and maintain airway during seizure
B. Administer antipyretic immediately
C. Call family to observe
D. Document seizure
A postoperative patient reports sudden chest pain radiating to the left arm. What is the first
action?
4
