HESI EXIT EXAM (E2) – QUESTIONS AND ANSWERS | VERIFIED
AND WELL DETAILED ANSWERS PLUS RATIONALES |
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1. A nurse is caring for a client admitted with acute heart failure who reports severe
dyspnea and orthopnea. The client is tachypneic with oxygen saturation at 88% on room
air. Which of the following actions should the nurse take first?
A. Administer sublingual nitroglycerin as prescribed.
B. Position the client in an upright position with legs dangling.
C. Obtain a stat 12-lead electrocardiogram.
D. Draw blood for B-type natriuretic peptide (BNP) levels.
ANSWER: B. Position the client in an upright position with legs dangling.
Placing the client in an upright position with the legs dangling (high-Fowler's position)
immediately decreases venous return (preload) to the right side of the heart, reducing
pulmonary congestion and improving gas exchange, which is the immediate priority. Option A
is incorrect because while nitroglycerin is used, positioning is the immediate non-
pharmacological priority. Option C and Option D are diagnostic steps that follow stabilization.
2. A nurse is assessing an older adult client who has been admitted with dehydration and
confusion. Which of the following findings should the nurse expect to find during the
assessment?
A. Bounding peripheral pulses and peripheral edema
B. Flattened neck veins and dry mucous membranes
C. Elevated blood pressure and distended neck veins
D. Crackles bilaterally in the lower lung fields
ANSWER: B. Flattened neck veins and dry mucous membranes
Dehydration results in hypovolemia, which manifests as flattened neck veins, dry mucous
membranes, poor skin turgor, tachycardia, and hypotension. Option A, Option C, and Option
D describe findings associated with fluid volume excess or hypervolemia.
3. A nurse is planning care for a client who is prescribed a continuous intravenous infusion
of regular insulin for diabetic ketoacidosis (DKA). Which of the following interventions
should be included in the plan?
A. Add 5% dextrose to the intravenous fluids when blood glucose reaches 250 to 300 mg/dL.
B. Discontinue the insulin infusion as soon as the client's blood glucose is below 400 mg/dL.
C. Administer subcutaneous insulin only after 7 days of continuous intravenous therapy.
,D. Check capillary blood glucose every 6 hours during the acute stabilization phase.
ANSWER: A. Add 5% dextrose to the intravenous fluids when blood glucose reaches 250 to
300 mg/dL.
Adding dextrose to IV fluids prevents hypoglycemia and cerebral edema as blood glucose
levels decline during aggressive insulin therapy for DKA. Option B is incorrect because
insulin must be continued until ketosis is resolved, not just when glucose drops. Option C is
incorrect because subcutaneous overlap is initiated much earlier. Option D is incorrect
because blood glucose is checked hourly during continuous insulin infusion.
4. A nurse is assessing a client who has a suspected bowel obstruction. Which of the
following findings is indicative of a high small bowel obstruction?
A. Early onset of copious, projectile vomiting containing fecal material
B. Gradual onset of abdominal distention with absolute constipation
C. Early onset of profuse, frequent vomiting with gastric contents or bile
D. Late development of severe fecal impaction and obstipation
ANSWER: C. Early onset of profuse, frequent vomiting with gastric contents or bile
A high small bowel obstruction typically presents early with projectile vomiting containing
stomach contents and bile, whereas lower obstructions present with marked abdominal
distention and late fecal vomiting. Option A is incorrect because fecal vomiting occurs late in
low obstructions. Option B and Option D describe large bowel or distal obstructions.
5. A nurse is caring for a client who is postoperative following a thyroidectomy. Which of
the following equipment must be kept immediately available at the client's bedside?
A. A mechanical blood pressure cuff and stethoscope
B. A standard nasal cannula and oxygen humidification setup
C. An emergency tracheostomy tray and suction equipment
D. A padded tongue blade and padded side rails
ANSWER: C. An emergency tracheostomy tray and suction equipment
Following a thyroidectomy, clients are at risk for acute airway obstruction caused by edema,
hemorrhage, or tetany. An emergency tracheostomy tray, oxygen, and suction must be
immediately available at the bedside. Option A, Option B, and Option D do not address the
immediate airway emergency risk associated with this specific surgery.
6. A nurse is reviewing the laboratory results of a client who has chronic kidney disease.
Which of the following findings should the nurse expect?
A. Serum calcium level of 10.5 mg/dL
B. Serum potassium level of 5.6 mEq/L
,C. Serum hemoglobin level of 15.0 g/dL
D. Serum phosphorus level of 2.5 mg/dL
ANSWER: B. Serum potassium level of 5.6 mEq/L
Chronic kidney disease impairs the kidneys' ability to excrete potassium, frequently leading to
hyperkalemia (normal range 3.5 to 5.0 mEq/L). Option A is incorrect because calcium is
typically low due to impaired vitamin D activation. Option C is incorrect because
erythropoietin deficiency causes anemia, resulting in low hemoglobin. Option D is incorrect
because phosphorus is retained, leading to hyperphosphatemia.
7. A nurse is planning care for a client who is prescribed lithium carbonate for bipolar
disorder. Which of the following instructions should the nurse include in the client teaching
plan?
A. "Restrict your daily intake of sodium and salty foods while taking this medication."
B. "Maintain a consistent daily fluid intake of 2,000 to 3,000 mL and normal salt intake."
C. "Take your daily dose immediately before strenuous exercise in hot weather."
D. "Avoid drinking any caffeinated beverages completely for the rest of your life."
ANSWER: B. Maintain a consistent daily fluid intake of 2,000 to 3,000 mL and normal salt
intake.
Lithium and sodium share reabsorption pathways in the renal tubules. Low sodium or
dehydration causes lithium retention and toxicity, making consistent fluid and sodium intake
essential. Option A is incorrect because sodium restriction increases lithium toxicity risk.
Option C is incorrect because heavy sweating without electrolyte replacement increases
toxicity. Option D is incorrect because moderate caffeine restriction may be advised, but
complete lifelong avoidance is unnecessary.
8. A nurse is assessing a client who has acute appendicitis. Where should the nurse expect
the client to feel localized pain and tenderness?
A. Right upper quadrant below the costal margin
B. Left lower quadrant near the descending colon
C. Right lower quadrant at McBurney's point
D. Periumbilical area radiating to the left flank
ANSWER: C. Right lower quadrant at McBurney's point
Acute appendicitis characteristically presents with right lower quadrant abdominal pain
localized at McBurney's point, often accompanied by rebound tenderness and low-grade fever.
Option A describes cholecystitis or biliary colic. Option B describes diverticulitis. Option D
describes early appendicitis referral or renal colic.
, 9. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a
central venous catheter. The current bag is nearly empty, and the next bag is not yet
available from the pharmacy. Which of the following intravenous solutions should the
nurse infuse immediately?
A. 0.9% Sodium Chloride with 20 mEq Potassium Chloride
B. 5% Dextrose in Water with multivitamin additives
C. 10% Dextrose in Water
D. 0.45% Sodium Chloride with 5% Dextrose
ANSWER: C. 10% Dextrose in Water
To prevent severe rebound hypoglycemia when TPN is abruptly interrupted, the nurse must
infuse an isotonic dextrose solution (such as 10% or 5% Dextrose in Water depending on
institutional protocol) at the same rate until the new TPN solution arrives. Option A lacks
dextrose and risks precipitating hypoglycemia. Option B and Option D do not match the
standard high dextrose concentration match required to bridge TPN formulas safely.
10. A nurse is caring for a client who has a chest tube connected to a water-seal drainage
system. Upon assessment, the nurse notes continuous bubbling in the water-seal chamber.
Which of the following actions should the nurse take?
A. Document the finding as a normal expected therapeutic response.
B. Increase the wall suction pressure until the bubbling stops.
C. Check the entire drainage system from insertion site to container for an air leak.
D. Elevate the drainage system above the level of the client's chest.
ANSWER: C. Check the entire drainage system from insertion site to container for an air
leak.
Continuous bubbling in the water-seal chamber indicates an active air leak in the system or
around the insertion site, which must be located and corrected. Option A is incorrect because
intermittent bubbling is normal during exhalation, but continuous bubbling indicates a leak.
Option B is incorrect because suction control regulates suction, not water-seal bubbling.
Option D is incorrect because the system must always remain below chest level.
11. A nurse is assessing a client who has a diagnosis of right-sided heart failure. Which of
the following findings should the nurse expect?
A. Exertional dyspnea and orthopnea
B. Jugular venous distention and dependent edema
C. Frothy, pink-tinged sputum and crackles
D. Dry, hacking cough worse at night
ANSWER: B. Jugular venous distention and dependent edema
AND WELL DETAILED ANSWERS PLUS RATIONALES |
GUARANTEED PASS | LATEST EXAM UPDATE | EXAM PREP |
STUDY GUIDE | PRACTICE TEST| DOWNLOAD INSTANT PDF
1. A nurse is caring for a client admitted with acute heart failure who reports severe
dyspnea and orthopnea. The client is tachypneic with oxygen saturation at 88% on room
air. Which of the following actions should the nurse take first?
A. Administer sublingual nitroglycerin as prescribed.
B. Position the client in an upright position with legs dangling.
C. Obtain a stat 12-lead electrocardiogram.
D. Draw blood for B-type natriuretic peptide (BNP) levels.
ANSWER: B. Position the client in an upright position with legs dangling.
Placing the client in an upright position with the legs dangling (high-Fowler's position)
immediately decreases venous return (preload) to the right side of the heart, reducing
pulmonary congestion and improving gas exchange, which is the immediate priority. Option A
is incorrect because while nitroglycerin is used, positioning is the immediate non-
pharmacological priority. Option C and Option D are diagnostic steps that follow stabilization.
2. A nurse is assessing an older adult client who has been admitted with dehydration and
confusion. Which of the following findings should the nurse expect to find during the
assessment?
A. Bounding peripheral pulses and peripheral edema
B. Flattened neck veins and dry mucous membranes
C. Elevated blood pressure and distended neck veins
D. Crackles bilaterally in the lower lung fields
ANSWER: B. Flattened neck veins and dry mucous membranes
Dehydration results in hypovolemia, which manifests as flattened neck veins, dry mucous
membranes, poor skin turgor, tachycardia, and hypotension. Option A, Option C, and Option
D describe findings associated with fluid volume excess or hypervolemia.
3. A nurse is planning care for a client who is prescribed a continuous intravenous infusion
of regular insulin for diabetic ketoacidosis (DKA). Which of the following interventions
should be included in the plan?
A. Add 5% dextrose to the intravenous fluids when blood glucose reaches 250 to 300 mg/dL.
B. Discontinue the insulin infusion as soon as the client's blood glucose is below 400 mg/dL.
C. Administer subcutaneous insulin only after 7 days of continuous intravenous therapy.
,D. Check capillary blood glucose every 6 hours during the acute stabilization phase.
ANSWER: A. Add 5% dextrose to the intravenous fluids when blood glucose reaches 250 to
300 mg/dL.
Adding dextrose to IV fluids prevents hypoglycemia and cerebral edema as blood glucose
levels decline during aggressive insulin therapy for DKA. Option B is incorrect because
insulin must be continued until ketosis is resolved, not just when glucose drops. Option C is
incorrect because subcutaneous overlap is initiated much earlier. Option D is incorrect
because blood glucose is checked hourly during continuous insulin infusion.
4. A nurse is assessing a client who has a suspected bowel obstruction. Which of the
following findings is indicative of a high small bowel obstruction?
A. Early onset of copious, projectile vomiting containing fecal material
B. Gradual onset of abdominal distention with absolute constipation
C. Early onset of profuse, frequent vomiting with gastric contents or bile
D. Late development of severe fecal impaction and obstipation
ANSWER: C. Early onset of profuse, frequent vomiting with gastric contents or bile
A high small bowel obstruction typically presents early with projectile vomiting containing
stomach contents and bile, whereas lower obstructions present with marked abdominal
distention and late fecal vomiting. Option A is incorrect because fecal vomiting occurs late in
low obstructions. Option B and Option D describe large bowel or distal obstructions.
5. A nurse is caring for a client who is postoperative following a thyroidectomy. Which of
the following equipment must be kept immediately available at the client's bedside?
A. A mechanical blood pressure cuff and stethoscope
B. A standard nasal cannula and oxygen humidification setup
C. An emergency tracheostomy tray and suction equipment
D. A padded tongue blade and padded side rails
ANSWER: C. An emergency tracheostomy tray and suction equipment
Following a thyroidectomy, clients are at risk for acute airway obstruction caused by edema,
hemorrhage, or tetany. An emergency tracheostomy tray, oxygen, and suction must be
immediately available at the bedside. Option A, Option B, and Option D do not address the
immediate airway emergency risk associated with this specific surgery.
6. A nurse is reviewing the laboratory results of a client who has chronic kidney disease.
Which of the following findings should the nurse expect?
A. Serum calcium level of 10.5 mg/dL
B. Serum potassium level of 5.6 mEq/L
,C. Serum hemoglobin level of 15.0 g/dL
D. Serum phosphorus level of 2.5 mg/dL
ANSWER: B. Serum potassium level of 5.6 mEq/L
Chronic kidney disease impairs the kidneys' ability to excrete potassium, frequently leading to
hyperkalemia (normal range 3.5 to 5.0 mEq/L). Option A is incorrect because calcium is
typically low due to impaired vitamin D activation. Option C is incorrect because
erythropoietin deficiency causes anemia, resulting in low hemoglobin. Option D is incorrect
because phosphorus is retained, leading to hyperphosphatemia.
7. A nurse is planning care for a client who is prescribed lithium carbonate for bipolar
disorder. Which of the following instructions should the nurse include in the client teaching
plan?
A. "Restrict your daily intake of sodium and salty foods while taking this medication."
B. "Maintain a consistent daily fluid intake of 2,000 to 3,000 mL and normal salt intake."
C. "Take your daily dose immediately before strenuous exercise in hot weather."
D. "Avoid drinking any caffeinated beverages completely for the rest of your life."
ANSWER: B. Maintain a consistent daily fluid intake of 2,000 to 3,000 mL and normal salt
intake.
Lithium and sodium share reabsorption pathways in the renal tubules. Low sodium or
dehydration causes lithium retention and toxicity, making consistent fluid and sodium intake
essential. Option A is incorrect because sodium restriction increases lithium toxicity risk.
Option C is incorrect because heavy sweating without electrolyte replacement increases
toxicity. Option D is incorrect because moderate caffeine restriction may be advised, but
complete lifelong avoidance is unnecessary.
8. A nurse is assessing a client who has acute appendicitis. Where should the nurse expect
the client to feel localized pain and tenderness?
A. Right upper quadrant below the costal margin
B. Left lower quadrant near the descending colon
C. Right lower quadrant at McBurney's point
D. Periumbilical area radiating to the left flank
ANSWER: C. Right lower quadrant at McBurney's point
Acute appendicitis characteristically presents with right lower quadrant abdominal pain
localized at McBurney's point, often accompanied by rebound tenderness and low-grade fever.
Option A describes cholecystitis or biliary colic. Option B describes diverticulitis. Option D
describes early appendicitis referral or renal colic.
, 9. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a
central venous catheter. The current bag is nearly empty, and the next bag is not yet
available from the pharmacy. Which of the following intravenous solutions should the
nurse infuse immediately?
A. 0.9% Sodium Chloride with 20 mEq Potassium Chloride
B. 5% Dextrose in Water with multivitamin additives
C. 10% Dextrose in Water
D. 0.45% Sodium Chloride with 5% Dextrose
ANSWER: C. 10% Dextrose in Water
To prevent severe rebound hypoglycemia when TPN is abruptly interrupted, the nurse must
infuse an isotonic dextrose solution (such as 10% or 5% Dextrose in Water depending on
institutional protocol) at the same rate until the new TPN solution arrives. Option A lacks
dextrose and risks precipitating hypoglycemia. Option B and Option D do not match the
standard high dextrose concentration match required to bridge TPN formulas safely.
10. A nurse is caring for a client who has a chest tube connected to a water-seal drainage
system. Upon assessment, the nurse notes continuous bubbling in the water-seal chamber.
Which of the following actions should the nurse take?
A. Document the finding as a normal expected therapeutic response.
B. Increase the wall suction pressure until the bubbling stops.
C. Check the entire drainage system from insertion site to container for an air leak.
D. Elevate the drainage system above the level of the client's chest.
ANSWER: C. Check the entire drainage system from insertion site to container for an air
leak.
Continuous bubbling in the water-seal chamber indicates an active air leak in the system or
around the insertion site, which must be located and corrected. Option A is incorrect because
intermittent bubbling is normal during exhalation, but continuous bubbling indicates a leak.
Option B is incorrect because suction control regulates suction, not water-seal bubbling.
Option D is incorrect because the system must always remain below chest level.
11. A nurse is assessing a client who has a diagnosis of right-sided heart failure. Which of
the following findings should the nurse expect?
A. Exertional dyspnea and orthopnea
B. Jugular venous distention and dependent edema
C. Frothy, pink-tinged sputum and crackles
D. Dry, hacking cough worse at night
ANSWER: B. Jugular venous distention and dependent edema
