, HESI EXIT V2
1. A client with chronic obstructive pulmonary disease (COPD) has an ABG result showing pH
7.30, PaCO₂ 60 mm Hg, PaO₂ 55 mm Hg, and HCO₃ 30 mEq/L. Which intervention should the
nurse implement FIRST?
A Administer a bronchodilator
B Apply supplemental oxygen at 2 L/min via nasal cannula
C Prepare for intubation
D Encourage incentive spirometry
Correct Answer: B
Rationale: The ABG shows respiratory acidosis with hypoxemia. The priority is to correct
hypoxemia by administering oxygen. Oxygen should be given cautiously, usually at 2 L/min, to
avoid suppressing the hypoxic drive in COPD clients .
2. A client with heart failure is receiving furosemide. Which finding indicates the medication is
having the desired effect?
A Serum potassium 3.2 mEq/L
B Weight loss of 2 kg in 24 hours
C Blood pressure 150/90 mm Hg
D Crackles auscultated in lung bases
Correct Answer: B
Rationale: Furosemide reduces fluid overload, and weight loss (1-2 kg/day) indicates effective
diuresis. Hypokalemia (A) is an adverse effect requiring monitoring. Crackles (D) indicate
unresolved fluid overload .
3. The nurse is caring for a client with cirrhosis who develops asterixis (liver flap). Which
laboratory value correlates with this finding?
A Elevated ammonia
B Low albumin
,C High bilirubin
D Low platelet count
Correct Answer: A
Rationale: Asterixis is a sign of hepatic encephalopathy caused by elevated ammonia levels.
Treatment focuses on reducing ammonia through lactulose and dietary protein modification .
4. A client with type 1 diabetes mellitus is found unresponsive with cool, clammy skin. What is
the priority action?
A Administer glucagon intramuscularly
B Check blood glucose level
C Administer IV dextrose 50%
D Notify the healthcare provider
Correct Answer: C
Rationale: The client is exhibiting signs of severe hypoglycemia (cool, clammy skin,
unresponsiveness). IV dextrose 50% is the fastest way to restore blood glucose in an
unresponsive client. Glucagon (A) is an alternative if IV access is not available .
5. A client is prescribed 1000 mL of 0.9% sodium chloride to infuse over 8 hours. The IV tubing
has a drop factor of 15 gtt/mL. At how many drops per minute should the nurse set the
infusion?
A 21 gtt/min
B 31 gtt/min
C 42 gtt/min
D 63 gtt/min
Correct Answer: B (31 gtt/min)
Rationale: The calculation is: 1000 mL ÷ 8 hours = 125 mL/hr. 125 mL/hr × 15 gtt/mL = 1875
gtt/hr. 1875 gtt/hr ÷ 60 min/hr = 31.25 gtt/min .
6. The nurse is assessing a client who is 1 day post-operative following a total hip arthroplasty.
Which finding requires immediate intervention?
, A The client reports pain of 4 on a scale of 0 to 10
B The operative leg is externally rotated
C The client's hemoglobin is 10.5 g/dL
D The client's temperature is 99.2°F (37.3°C)
Correct Answer: B
Rationale: External rotation of the operative leg may indicate dislocation of the hip prosthesis,
which is a medical emergency requiring immediate intervention. Pain (A) is expected post-
operatively. Hemoglobin of 10.5 g/dL (C) is slightly low but expected after surgery. Temperature
of 99.2°F (D) is within normal limits.
7. A nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which
intervention should the nurse implement FIRST?
A Increase humidity via tracheostomy collar
B Perform tracheal suctioning
C Instill normal saline into the tracheostomy tube
D Change the inner cannula
Correct Answer: A
Rationale: Increasing humidity helps loosen thick secretions, making suctioning more effective
and less traumatic. Instilling saline is no longer recommended as it can cause mucosal damage .
8. The nurse is caring for a client receiving a blood transfusion. Fifteen minutes after initiation,
the client reports low back pain and chills. Which action should the nurse take FIRST?
A Stop the transfusion
B Administer acetaminophen
C Obtain a urine specimen
D Notify the provider
Correct Answer: A
Rationale: Low back pain and chills indicate a possible hemolytic transfusion reaction. The
transfusion must be stopped immediately to prevent further complications. The IV line should
be kept open with normal saline .
1. A client with chronic obstructive pulmonary disease (COPD) has an ABG result showing pH
7.30, PaCO₂ 60 mm Hg, PaO₂ 55 mm Hg, and HCO₃ 30 mEq/L. Which intervention should the
nurse implement FIRST?
A Administer a bronchodilator
B Apply supplemental oxygen at 2 L/min via nasal cannula
C Prepare for intubation
D Encourage incentive spirometry
Correct Answer: B
Rationale: The ABG shows respiratory acidosis with hypoxemia. The priority is to correct
hypoxemia by administering oxygen. Oxygen should be given cautiously, usually at 2 L/min, to
avoid suppressing the hypoxic drive in COPD clients .
2. A client with heart failure is receiving furosemide. Which finding indicates the medication is
having the desired effect?
A Serum potassium 3.2 mEq/L
B Weight loss of 2 kg in 24 hours
C Blood pressure 150/90 mm Hg
D Crackles auscultated in lung bases
Correct Answer: B
Rationale: Furosemide reduces fluid overload, and weight loss (1-2 kg/day) indicates effective
diuresis. Hypokalemia (A) is an adverse effect requiring monitoring. Crackles (D) indicate
unresolved fluid overload .
3. The nurse is caring for a client with cirrhosis who develops asterixis (liver flap). Which
laboratory value correlates with this finding?
A Elevated ammonia
B Low albumin
,C High bilirubin
D Low platelet count
Correct Answer: A
Rationale: Asterixis is a sign of hepatic encephalopathy caused by elevated ammonia levels.
Treatment focuses on reducing ammonia through lactulose and dietary protein modification .
4. A client with type 1 diabetes mellitus is found unresponsive with cool, clammy skin. What is
the priority action?
A Administer glucagon intramuscularly
B Check blood glucose level
C Administer IV dextrose 50%
D Notify the healthcare provider
Correct Answer: C
Rationale: The client is exhibiting signs of severe hypoglycemia (cool, clammy skin,
unresponsiveness). IV dextrose 50% is the fastest way to restore blood glucose in an
unresponsive client. Glucagon (A) is an alternative if IV access is not available .
5. A client is prescribed 1000 mL of 0.9% sodium chloride to infuse over 8 hours. The IV tubing
has a drop factor of 15 gtt/mL. At how many drops per minute should the nurse set the
infusion?
A 21 gtt/min
B 31 gtt/min
C 42 gtt/min
D 63 gtt/min
Correct Answer: B (31 gtt/min)
Rationale: The calculation is: 1000 mL ÷ 8 hours = 125 mL/hr. 125 mL/hr × 15 gtt/mL = 1875
gtt/hr. 1875 gtt/hr ÷ 60 min/hr = 31.25 gtt/min .
6. The nurse is assessing a client who is 1 day post-operative following a total hip arthroplasty.
Which finding requires immediate intervention?
, A The client reports pain of 4 on a scale of 0 to 10
B The operative leg is externally rotated
C The client's hemoglobin is 10.5 g/dL
D The client's temperature is 99.2°F (37.3°C)
Correct Answer: B
Rationale: External rotation of the operative leg may indicate dislocation of the hip prosthesis,
which is a medical emergency requiring immediate intervention. Pain (A) is expected post-
operatively. Hemoglobin of 10.5 g/dL (C) is slightly low but expected after surgery. Temperature
of 99.2°F (D) is within normal limits.
7. A nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which
intervention should the nurse implement FIRST?
A Increase humidity via tracheostomy collar
B Perform tracheal suctioning
C Instill normal saline into the tracheostomy tube
D Change the inner cannula
Correct Answer: A
Rationale: Increasing humidity helps loosen thick secretions, making suctioning more effective
and less traumatic. Instilling saline is no longer recommended as it can cause mucosal damage .
8. The nurse is caring for a client receiving a blood transfusion. Fifteen minutes after initiation,
the client reports low back pain and chills. Which action should the nurse take FIRST?
A Stop the transfusion
B Administer acetaminophen
C Obtain a urine specimen
D Notify the provider
Correct Answer: A
Rationale: Low back pain and chills indicate a possible hemolytic transfusion reaction. The
transfusion must be stopped immediately to prevent further complications. The IV line should
be kept open with normal saline .
