HESI RN EXIT EXAM V1 - COMPREHENSIVE EXAM QUESTIONS
COMPLETE WITH 100% VERIFIED ANSWERS
1. A client with heart failure is prescribed digoxin. Which assessment
finding indicates the client is experiencing digoxin toxicity?
A. Heart rate of 62 beats per minute
B. Serum potassium level of 3.2 mEq/L
C. Serum digoxin level of 1.8 ng/mL
D. Blood pressure of 130/80 mmHg
Correct Answer: B
Rationale: Hypokalemia (potassium < 3.5 mEq/L) increases the risk of
digoxin toxicity. A serum potassium of 3.2 mEq/L places this client at
high risk. Normal digoxin level is 0.8-2.0 ng/mL; a heart rate of 62 is
acceptable; blood pressure of 130/80 is within normal limits.
2. A postoperative client reports sudden chest pain and shortness of
breath. The nurse notes tachycardia and hypotension. Which action
should the nurse take first?
A. Administer prescribed pain medication
B. Place the client in high Fowler's position
C. Apply oxygen at 2 L/min via nasal cannula
D. Notify the healthcare provider immediately
,Correct Answer: C
Rationale: The client is exhibiting signs of a pulmonary embolism. The
priority intervention is to apply oxygen to address hypoxia. High
Fowler's position, notifying the provider, and pain management are
important but oxygenation is the immediate priority.
3. A client with chronic obstructive pulmonary disease (COPD) has an
arterial blood gas (ABG) result showing pH 7.32, PaCO2 58 mmHg, and
HCO3 30 mEq/L. The nurse interprets this as which acid-base
imbalance?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Correct Answer: C
Rationale: The pH is low (acidosis), PaCO2 is elevated (> 45 mmHg), and
HCO3 is elevated (compensatory). This indicates respiratory acidosis
with partial compensation, which is expected in COPD clients with CO2
retention.
4. A client receiving chemotherapy develops stomatitis. Which
intervention should the nurse include in the plan of care?
A. Encourage citrus fruits to promote healing
B. Use a soft-bristled toothbrush for oral care
,C. Apply alcohol-based mouthwash four times daily
D. Provide hot liquids to decrease discomfort
Correct Answer: B
Rationale: Stomatitis causes oral mucosal inflammation and ulceration.
A soft-bristled toothbrush minimizes trauma to tissues. Citrus fruits,
alcohol-based products, and hot liquids would further irritate the
mucosa.
5. The nurse is caring for a client with tuberculosis who is receiving
isoniazid. Which dietary instruction is most important for the nurse to
provide?
A. Avoid foods high in tyramine
B. Consume foods rich in vitamin B6
C. Increase intake of green leafy vegetables
D. Avoid foods high in potassium
Correct Answer: B
Rationale: Isoniazid can cause peripheral neuropathy due to vitamin B6
(pyridoxine) deficiency. Clients should consume foods rich in vitamin B6
such as poultry, fish, and bananas. Tyramine restriction applies to MAOI
medications.
6. A client with diabetes mellitus type 1 presents with fruity breath
odor, Kussmaul respirations, and blood glucose of 450 mg/dL. Which
intervention should the nurse anticipate?
, A. Administration of oral hypoglycemic agents
B. Intravenous infusion of regular insulin
C. Administration of glucagon
D. Subcutaneous injection of NPH insulin
Correct Answer: B
Rationale: The client is in diabetic ketoacidosis (DKA). Treatment
requires IV regular insulin to rapidly decrease blood glucose. Oral
agents are ineffective in DKA; glucagon is for hypoglycemia; NPH is not
used for acute hyperglycemic emergencies.
7. The nurse is assessing a client with cirrhosis who has ascites. Which
finding indicates that the client's condition is worsening?
A. Weight gain of 2 kg in 24 hours
B. Blood pressure of 118/76 mmHg
C. Serum albumin of 3.8 g/dL
D. Flat jugular veins in supine position
Correct Answer: A
Rationale: A weight gain of 2 kg in 24 hours indicates rapid fluid
accumulation, suggesting worsening ascites and fluid retention. This is
the most concerning finding and requires immediate intervention.
8. A client with major depressive disorder is prescribed phenelzine.
Which food item should the nurse instruct the client to avoid?
COMPLETE WITH 100% VERIFIED ANSWERS
1. A client with heart failure is prescribed digoxin. Which assessment
finding indicates the client is experiencing digoxin toxicity?
A. Heart rate of 62 beats per minute
B. Serum potassium level of 3.2 mEq/L
C. Serum digoxin level of 1.8 ng/mL
D. Blood pressure of 130/80 mmHg
Correct Answer: B
Rationale: Hypokalemia (potassium < 3.5 mEq/L) increases the risk of
digoxin toxicity. A serum potassium of 3.2 mEq/L places this client at
high risk. Normal digoxin level is 0.8-2.0 ng/mL; a heart rate of 62 is
acceptable; blood pressure of 130/80 is within normal limits.
2. A postoperative client reports sudden chest pain and shortness of
breath. The nurse notes tachycardia and hypotension. Which action
should the nurse take first?
A. Administer prescribed pain medication
B. Place the client in high Fowler's position
C. Apply oxygen at 2 L/min via nasal cannula
D. Notify the healthcare provider immediately
,Correct Answer: C
Rationale: The client is exhibiting signs of a pulmonary embolism. The
priority intervention is to apply oxygen to address hypoxia. High
Fowler's position, notifying the provider, and pain management are
important but oxygenation is the immediate priority.
3. A client with chronic obstructive pulmonary disease (COPD) has an
arterial blood gas (ABG) result showing pH 7.32, PaCO2 58 mmHg, and
HCO3 30 mEq/L. The nurse interprets this as which acid-base
imbalance?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Correct Answer: C
Rationale: The pH is low (acidosis), PaCO2 is elevated (> 45 mmHg), and
HCO3 is elevated (compensatory). This indicates respiratory acidosis
with partial compensation, which is expected in COPD clients with CO2
retention.
4. A client receiving chemotherapy develops stomatitis. Which
intervention should the nurse include in the plan of care?
A. Encourage citrus fruits to promote healing
B. Use a soft-bristled toothbrush for oral care
,C. Apply alcohol-based mouthwash four times daily
D. Provide hot liquids to decrease discomfort
Correct Answer: B
Rationale: Stomatitis causes oral mucosal inflammation and ulceration.
A soft-bristled toothbrush minimizes trauma to tissues. Citrus fruits,
alcohol-based products, and hot liquids would further irritate the
mucosa.
5. The nurse is caring for a client with tuberculosis who is receiving
isoniazid. Which dietary instruction is most important for the nurse to
provide?
A. Avoid foods high in tyramine
B. Consume foods rich in vitamin B6
C. Increase intake of green leafy vegetables
D. Avoid foods high in potassium
Correct Answer: B
Rationale: Isoniazid can cause peripheral neuropathy due to vitamin B6
(pyridoxine) deficiency. Clients should consume foods rich in vitamin B6
such as poultry, fish, and bananas. Tyramine restriction applies to MAOI
medications.
6. A client with diabetes mellitus type 1 presents with fruity breath
odor, Kussmaul respirations, and blood glucose of 450 mg/dL. Which
intervention should the nurse anticipate?
, A. Administration of oral hypoglycemic agents
B. Intravenous infusion of regular insulin
C. Administration of glucagon
D. Subcutaneous injection of NPH insulin
Correct Answer: B
Rationale: The client is in diabetic ketoacidosis (DKA). Treatment
requires IV regular insulin to rapidly decrease blood glucose. Oral
agents are ineffective in DKA; glucagon is for hypoglycemia; NPH is not
used for acute hyperglycemic emergencies.
7. The nurse is assessing a client with cirrhosis who has ascites. Which
finding indicates that the client's condition is worsening?
A. Weight gain of 2 kg in 24 hours
B. Blood pressure of 118/76 mmHg
C. Serum albumin of 3.8 g/dL
D. Flat jugular veins in supine position
Correct Answer: A
Rationale: A weight gain of 2 kg in 24 hours indicates rapid fluid
accumulation, suggesting worsening ascites and fluid retention. This is
the most concerning finding and requires immediate intervention.
8. A client with major depressive disorder is prescribed phenelzine.
Which food item should the nurse instruct the client to avoid?
