HESI Exit Exam Questions and Correct Answers
(Verified Answers) Plus Rationales 2026 Q&A |
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1. A nurse is caring for a client diagnosed with heart failure who
reports increasing shortness of breath while lying flat. Which
intervention should the nurse implement first?
A. Administer a prescribed diuretic
B. Place the client in a high-Fowler's position
C. Restrict oral fluids
D. Obtain a chest X-ray
Correct Answer: B. Place the client in a high-Fowler's position
Rationale: The priority is to improve oxygenation and reduce venous
return by positioning the client upright. High-Fowler's position
promotes lung expansion and decreases preload, providing immediate
symptom relief. Administering medications is important but should
follow airway and breathing interventions according to ABC priorities.
, 2. A client with type 1 diabetes is found unconscious. The nurse
notes the client's blood glucose is 38 mg/dL. Which action is the
priority?
A. Administer regular insulin
B. Offer orange juice
C. Administer IV dextrose
D. Recheck the blood glucose in 30 minutes
Rationale: An unconscious client cannot safely swallow. IV dextrose
rapidly corrects severe hypoglycemia and is the priority intervention. If
IV access is unavailable, glucagon may be administered. Oral
carbohydrates are only appropriate for conscious clients.
3. Which assessment finding requires immediate intervention in a
postoperative client?
A. Temperature of 99.5°F (37.5°C)
B. Pain rated 6/10
C. Oxygen saturation of 88%
D. Heart rate of 102 beats/minute
,Rationale: An oxygen saturation of 88% indicates hypoxemia requiring
immediate intervention. Airway and oxygenation always take priority
over pain, mild fever, or slight tachycardia in the postoperative period.
4. A nurse is teaching a client about warfarin therapy. Which food
should the client consume consistently?
A. Grapefruit
B. Cranberry juice
C. Green leafy vegetables
D. Garlic supplements
Rationale: Foods high in vitamin K, such as green leafy vegetables,
should be consumed consistently while taking warfarin. Large
fluctuations in vitamin K intake can alter the medication's
effectiveness and increase the risk for bleeding or clotting.
5. Which laboratory value should the nurse report immediately?
A. Sodium 138 mEq/L
B. Potassium 3.8 mEq/L
C. Potassium 6.2 mEq/L
D. Calcium 9.1 mg/dL
, Rationale: A potassium level of 6.2 mEq/L indicates severe
hyperkalemia, placing the client at risk for life-threatening cardiac
dysrhythmias. Immediate intervention and provider notification are
required.
6. A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen. Which assessment finding indicates oxygen
therapy is effective?
A. Increased productive cough
B. Respiratory rate of 32/minute
C. Oxygen saturation of 92%
D. Increased wheezing
Rationale: Maintaining oxygen saturation between approximately
88% and 92% is generally the target for many clients with COPD to
improve oxygenation while minimizing the risk of suppressing
respiratory drive in susceptible individuals.
7. Which client should the nurse assess first?
A. Client requesting pain medication
B. Client awaiting discharge instructions
(Verified Answers) Plus Rationales 2026 Q&A |
Instant Download Pdf
1. A nurse is caring for a client diagnosed with heart failure who
reports increasing shortness of breath while lying flat. Which
intervention should the nurse implement first?
A. Administer a prescribed diuretic
B. Place the client in a high-Fowler's position
C. Restrict oral fluids
D. Obtain a chest X-ray
Correct Answer: B. Place the client in a high-Fowler's position
Rationale: The priority is to improve oxygenation and reduce venous
return by positioning the client upright. High-Fowler's position
promotes lung expansion and decreases preload, providing immediate
symptom relief. Administering medications is important but should
follow airway and breathing interventions according to ABC priorities.
, 2. A client with type 1 diabetes is found unconscious. The nurse
notes the client's blood glucose is 38 mg/dL. Which action is the
priority?
A. Administer regular insulin
B. Offer orange juice
C. Administer IV dextrose
D. Recheck the blood glucose in 30 minutes
Rationale: An unconscious client cannot safely swallow. IV dextrose
rapidly corrects severe hypoglycemia and is the priority intervention. If
IV access is unavailable, glucagon may be administered. Oral
carbohydrates are only appropriate for conscious clients.
3. Which assessment finding requires immediate intervention in a
postoperative client?
A. Temperature of 99.5°F (37.5°C)
B. Pain rated 6/10
C. Oxygen saturation of 88%
D. Heart rate of 102 beats/minute
,Rationale: An oxygen saturation of 88% indicates hypoxemia requiring
immediate intervention. Airway and oxygenation always take priority
over pain, mild fever, or slight tachycardia in the postoperative period.
4. A nurse is teaching a client about warfarin therapy. Which food
should the client consume consistently?
A. Grapefruit
B. Cranberry juice
C. Green leafy vegetables
D. Garlic supplements
Rationale: Foods high in vitamin K, such as green leafy vegetables,
should be consumed consistently while taking warfarin. Large
fluctuations in vitamin K intake can alter the medication's
effectiveness and increase the risk for bleeding or clotting.
5. Which laboratory value should the nurse report immediately?
A. Sodium 138 mEq/L
B. Potassium 3.8 mEq/L
C. Potassium 6.2 mEq/L
D. Calcium 9.1 mg/dL
, Rationale: A potassium level of 6.2 mEq/L indicates severe
hyperkalemia, placing the client at risk for life-threatening cardiac
dysrhythmias. Immediate intervention and provider notification are
required.
6. A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen. Which assessment finding indicates oxygen
therapy is effective?
A. Increased productive cough
B. Respiratory rate of 32/minute
C. Oxygen saturation of 92%
D. Increased wheezing
Rationale: Maintaining oxygen saturation between approximately
88% and 92% is generally the target for many clients with COPD to
improve oxygenation while minimizing the risk of suppressing
respiratory drive in susceptible individuals.
7. Which client should the nurse assess first?
A. Client requesting pain medication
B. Client awaiting discharge instructions
