, HESI EXIT V3
1. 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, the nurse notes 300 mL 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 finding 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 the placement of a central venous catheter.
D Increase the infusion rate of Lactated Ringer's solution.
Correct Answer: D
Rationale: The client has lost a significant amount of blood (300 mL in one hour
indicates acute blood loss), and the immediate concern is preventing hypovolemic shock
progression. Tachycardia at 155 beats/minute and hypotension at 78/48 mmHg
demonstrate shocky hemodynamics. Increasing the IV fluid rate gives an immediate
intravascular volume boost while awaiting further orders (e.g., blood transfusion). It is
critical to maintain blood pressure and perfusion to vital organs. Other actions, like
measuring urine output and obtaining packed RBCs, are important but do not
supersede rapidly restoring intravascular volume .
2. 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 before his transfer to the 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 was 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 auto-transfusion.
C Manipulate blood in tubing to drain into chamber.
D Increase wall suction to eliminate fluctuation in water seal.
Correct Answer: A
,Rationale: The suction control chamber should be filled with sterile water to the
prescribed level (−10 cm H₂O). Bubbling at the correct level indicates suction is
functioning. Fluctuation in the water seal (tidaling) is normal. Bright red blood drainage
should be monitored but 75 mL over an hour is not immediately critical. Auto-
transfusion (B) requires specific orders. Manipulating tubing (C) is not appropriate.
Fluctuation in the water seal is expected and should not be eliminated (D) .
3. A patient with heart failure is prescribed furosemide (Lasix). Which laboratory value
should the nurse monitor most closely?
A Serum sodium
B Serum potassium
C Serum calcium
D Serum magnesium
Correct Answer: B
Rationale: Furosemide is a loop diuretic that causes potassium wasting, leading to
hypokalemia, which increases the risk of digoxin toxicity and arrhythmias. While sodium
(A), calcium (C), and magnesium (D) should be monitored, potassium is the most critical
parameter .
4. A patient with chronic obstructive pulmonary disease (COPD) has a PaCO₂ of 68
mmHg and an SpO₂ of 88% on room air. The nurse should administer oxygen at:
A 2 L/min via nasal cannula
B 4 L/min via nasal cannula
C 6 L/min via simple mask
D 10 L/min via non-rebreather mask
Correct Answer: A
Rationale: COPD patients with chronic hypercapnia rely on hypoxic drive; high oxygen
can suppress respiratory drive. Target SpO₂ is 88-92%, starting at 1-2 L/min via nasal
cannula. Higher flow rates (B, C, D) risk respiratory depression and CO₂ retention .
, 5. A patient with type 1 diabetes mellitus is found unconscious. The blood glucose
reading is 45 mg/dL. The nurse should FIRST:
A Administer 50% dextrose IV push
B Give 15 grams of oral carbohydrate
C Administer glucagon IM
D Recheck blood glucose in 15 minutes
Correct Answer: A
Rationale: An unconscious patient cannot swallow safely; IV dextrose is the priority
treatment for severe hypoglycemia. Glucagon IM (C) is used if no IV access is available.
Oral carbohydrates (B) are contraindicated in an unconscious client due to aspiration
risk .
6. Which finding in a patient with a new cast on the lower leg is most concerning for
compartment syndrome?
A Pain that is relieved by elevation
B Toes that are pink and warm
C Pain that worsens with passive extension of the toes
D Mild swelling around the cast edges
Correct Answer: C
Rationale: Pain out of proportion to injury that worsens with passive stretch is an early
sign of compartment syndrome. Pain relieved by elevation (A) is not typical;
compartment syndrome pain is not relieved by elevation. Pink, warm toes (B) indicate
adequate perfusion. Mild swelling (D) is expected with a new cast .
7. A patient with peptic ulcer disease is prescribed omeprazole (Prilosec). The nurse
should instruct the patient to take this medication:
1. 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, the nurse notes 300 mL 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 finding 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 the placement of a central venous catheter.
D Increase the infusion rate of Lactated Ringer's solution.
Correct Answer: D
Rationale: The client has lost a significant amount of blood (300 mL in one hour
indicates acute blood loss), and the immediate concern is preventing hypovolemic shock
progression. Tachycardia at 155 beats/minute and hypotension at 78/48 mmHg
demonstrate shocky hemodynamics. Increasing the IV fluid rate gives an immediate
intravascular volume boost while awaiting further orders (e.g., blood transfusion). It is
critical to maintain blood pressure and perfusion to vital organs. Other actions, like
measuring urine output and obtaining packed RBCs, are important but do not
supersede rapidly restoring intravascular volume .
2. 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 before his transfer to the 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 was 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 auto-transfusion.
C Manipulate blood in tubing to drain into chamber.
D Increase wall suction to eliminate fluctuation in water seal.
Correct Answer: A
,Rationale: The suction control chamber should be filled with sterile water to the
prescribed level (−10 cm H₂O). Bubbling at the correct level indicates suction is
functioning. Fluctuation in the water seal (tidaling) is normal. Bright red blood drainage
should be monitored but 75 mL over an hour is not immediately critical. Auto-
transfusion (B) requires specific orders. Manipulating tubing (C) is not appropriate.
Fluctuation in the water seal is expected and should not be eliminated (D) .
3. A patient with heart failure is prescribed furosemide (Lasix). Which laboratory value
should the nurse monitor most closely?
A Serum sodium
B Serum potassium
C Serum calcium
D Serum magnesium
Correct Answer: B
Rationale: Furosemide is a loop diuretic that causes potassium wasting, leading to
hypokalemia, which increases the risk of digoxin toxicity and arrhythmias. While sodium
(A), calcium (C), and magnesium (D) should be monitored, potassium is the most critical
parameter .
4. A patient with chronic obstructive pulmonary disease (COPD) has a PaCO₂ of 68
mmHg and an SpO₂ of 88% on room air. The nurse should administer oxygen at:
A 2 L/min via nasal cannula
B 4 L/min via nasal cannula
C 6 L/min via simple mask
D 10 L/min via non-rebreather mask
Correct Answer: A
Rationale: COPD patients with chronic hypercapnia rely on hypoxic drive; high oxygen
can suppress respiratory drive. Target SpO₂ is 88-92%, starting at 1-2 L/min via nasal
cannula. Higher flow rates (B, C, D) risk respiratory depression and CO₂ retention .
, 5. A patient with type 1 diabetes mellitus is found unconscious. The blood glucose
reading is 45 mg/dL. The nurse should FIRST:
A Administer 50% dextrose IV push
B Give 15 grams of oral carbohydrate
C Administer glucagon IM
D Recheck blood glucose in 15 minutes
Correct Answer: A
Rationale: An unconscious patient cannot swallow safely; IV dextrose is the priority
treatment for severe hypoglycemia. Glucagon IM (C) is used if no IV access is available.
Oral carbohydrates (B) are contraindicated in an unconscious client due to aspiration
risk .
6. Which finding in a patient with a new cast on the lower leg is most concerning for
compartment syndrome?
A Pain that is relieved by elevation
B Toes that are pink and warm
C Pain that worsens with passive extension of the toes
D Mild swelling around the cast edges
Correct Answer: C
Rationale: Pain out of proportion to injury that worsens with passive stretch is an early
sign of compartment syndrome. Pain relieved by elevation (A) is not typical;
compartment syndrome pain is not relieved by elevation. Pink, warm toes (B) indicate
adequate perfusion. Mild swelling (D) is expected with a new cast .
7. A patient with peptic ulcer disease is prescribed omeprazole (Prilosec). The nurse
should instruct the patient to take this medication:
