1
. RN
HESI EXIT EXAM - VERSION 3 (V3) ALL 200
QUESTIONS & ANSWERS INCLUDED -
GUARANTEED PASS A+!!! ALL BRAND NEW
1.
A nurse is caring for a 68-year-old client who was admitted to the
medical-surgical unit with an acute exacerbation of chronic heart failure.
The client reports increasing shortness of breath when lying flat and has
gained 3.2 kg (7 lb) during the past week. Assessment reveals bilateral
crackles extending halfway up the posterior lung fields, 3+ bilateral
lower-extremity edema, jugular venous distention, and an oxygen
saturation of 88% on room air. Which intervention should the nurse
implement first?
A. Administer the prescribed intravenous loop diuretic and reassess
urine output.
B. Place the client in a high-Fowler position and apply supplemental
oxygen as prescribed.
C. Restrict the client's oral fluid intake to 1,000 mL over the next 24
hours.
D. Obtain the client's morning weight and compare it with the admission
weight.
Answer: B
2.
A client with type 1 diabetes mellitus is admitted with nausea, vomiting,
abdominal pain, and increasing lethargy. Laboratory results reveal a
blood glucose level of 468 mg/dL, arterial pH of 7.19, bicarbonate of 11
mEq/L, and positive serum ketones. The nurse notes deep, rapid
respirations and a fruity odor to the client's breath. Which prescription
should the nurse anticipate implementing as the priority treatment?
,2
A. Administer regular insulin intravenously according to the prescribed
protocol.
B. Administer long-acting insulin subcutaneously and provide a
carbohydrate snack.
C. Administer sodium bicarbonate immediately regardless of the client's
potassium level.
D. Restrict intravenous fluids to prevent worsening cerebral edema.
Answer: A
3.
A postoperative client who underwent abdominal surgery 24 hours ago
suddenly reports sharp chest pain and severe shortness of breath. The
client appears anxious and restless, has a respiratory rate of 32/min,
heart rate of 124/min, and oxygen saturation of 84% despite receiving
oxygen by nasal cannula. The nurse suspects a pulmonary embolism.
Which action is most appropriate?
A. Encourage the client to ambulate to improve pulmonary circulation.
B. Place the client in a supine position and encourage coughing
exercises.
C. Apply high-concentration oxygen, remain with the client, and notify
the healthcare provider immediately.
D. Administer the prescribed oral analgesic and reassess the client after
30 minutes.
Answer: C
4.
A nurse is preparing to administer digoxin to an older adult client with
heart failure. The client reports nausea and seeing yellow-green halos
,3
around objects. The apical pulse is 54 beats/minute, and the client states
that the symptoms began earlier that morning. Which action should the
nurse take?
A. Administer the medication because the symptoms are expected
adverse effects.
B. Hold the medication and notify the healthcare provider.
C. Administer the medication with food to reduce gastrointestinal
symptoms.
D. Give an additional dose because the pulse is below the client's normal
baseline.
Answer: B
5.
A client receiving a continuous intravenous infusion of unfractionated
heparin for treatment of a deep-vein thrombosis suddenly develops
severe abdominal pain and hypotension. The client's blood pressure is
82/48 mmHg, heart rate is 118/min, and the abdomen is distended and
tender. Which nursing action has the highest priority?
A. Continue the infusion and obtain a routine aPTT level.
B. Stop the heparin infusion and notify the healthcare provider
immediately.
C. Administer the next scheduled dose of warfarin.
D. Encourage oral fluids to correct the client's hypotension.
Answer: B
6.
, 4
A nurse is caring for a client who has been receiving chemotherapy and
whose absolute neutrophil count is significantly decreased. The client
has a temperature of 38.6°C (101.5°F), chills, and generalized weakness.
Which action should the nurse take first?
A. Place fresh flowers in the client's room to improve emotional well-
being.
B. Administer acetaminophen and reassess the temperature in four
hours.
C. Notify the healthcare provider immediately because the client may
have neutropenic fever.
D. Encourage the client to eat raw fruits and vegetables to increase
vitamin intake.
Answer: C
7.
A client with chronic obstructive pulmonary disease is receiving oxygen
at 2 L/min via nasal cannula. The client becomes increasingly drowsy
and difficult to arouse. Respiratory rate decreases from 20/min to
10/min, and the oxygen saturation is 96%. Which action should the
nurse take?
A. Increase the oxygen flow rate to 6 L/min.
B. Remove the oxygen and leave the client unattended.
C. Assess the client's respiratory status and notify the healthcare
provider immediately.
D. Encourage the client to sleep because rest reduces oxygen
consumption.
Answer: C
. RN
HESI EXIT EXAM - VERSION 3 (V3) ALL 200
QUESTIONS & ANSWERS INCLUDED -
GUARANTEED PASS A+!!! ALL BRAND NEW
1.
A nurse is caring for a 68-year-old client who was admitted to the
medical-surgical unit with an acute exacerbation of chronic heart failure.
The client reports increasing shortness of breath when lying flat and has
gained 3.2 kg (7 lb) during the past week. Assessment reveals bilateral
crackles extending halfway up the posterior lung fields, 3+ bilateral
lower-extremity edema, jugular venous distention, and an oxygen
saturation of 88% on room air. Which intervention should the nurse
implement first?
A. Administer the prescribed intravenous loop diuretic and reassess
urine output.
B. Place the client in a high-Fowler position and apply supplemental
oxygen as prescribed.
C. Restrict the client's oral fluid intake to 1,000 mL over the next 24
hours.
D. Obtain the client's morning weight and compare it with the admission
weight.
Answer: B
2.
A client with type 1 diabetes mellitus is admitted with nausea, vomiting,
abdominal pain, and increasing lethargy. Laboratory results reveal a
blood glucose level of 468 mg/dL, arterial pH of 7.19, bicarbonate of 11
mEq/L, and positive serum ketones. The nurse notes deep, rapid
respirations and a fruity odor to the client's breath. Which prescription
should the nurse anticipate implementing as the priority treatment?
,2
A. Administer regular insulin intravenously according to the prescribed
protocol.
B. Administer long-acting insulin subcutaneously and provide a
carbohydrate snack.
C. Administer sodium bicarbonate immediately regardless of the client's
potassium level.
D. Restrict intravenous fluids to prevent worsening cerebral edema.
Answer: A
3.
A postoperative client who underwent abdominal surgery 24 hours ago
suddenly reports sharp chest pain and severe shortness of breath. The
client appears anxious and restless, has a respiratory rate of 32/min,
heart rate of 124/min, and oxygen saturation of 84% despite receiving
oxygen by nasal cannula. The nurse suspects a pulmonary embolism.
Which action is most appropriate?
A. Encourage the client to ambulate to improve pulmonary circulation.
B. Place the client in a supine position and encourage coughing
exercises.
C. Apply high-concentration oxygen, remain with the client, and notify
the healthcare provider immediately.
D. Administer the prescribed oral analgesic and reassess the client after
30 minutes.
Answer: C
4.
A nurse is preparing to administer digoxin to an older adult client with
heart failure. The client reports nausea and seeing yellow-green halos
,3
around objects. The apical pulse is 54 beats/minute, and the client states
that the symptoms began earlier that morning. Which action should the
nurse take?
A. Administer the medication because the symptoms are expected
adverse effects.
B. Hold the medication and notify the healthcare provider.
C. Administer the medication with food to reduce gastrointestinal
symptoms.
D. Give an additional dose because the pulse is below the client's normal
baseline.
Answer: B
5.
A client receiving a continuous intravenous infusion of unfractionated
heparin for treatment of a deep-vein thrombosis suddenly develops
severe abdominal pain and hypotension. The client's blood pressure is
82/48 mmHg, heart rate is 118/min, and the abdomen is distended and
tender. Which nursing action has the highest priority?
A. Continue the infusion and obtain a routine aPTT level.
B. Stop the heparin infusion and notify the healthcare provider
immediately.
C. Administer the next scheduled dose of warfarin.
D. Encourage oral fluids to correct the client's hypotension.
Answer: B
6.
, 4
A nurse is caring for a client who has been receiving chemotherapy and
whose absolute neutrophil count is significantly decreased. The client
has a temperature of 38.6°C (101.5°F), chills, and generalized weakness.
Which action should the nurse take first?
A. Place fresh flowers in the client's room to improve emotional well-
being.
B. Administer acetaminophen and reassess the temperature in four
hours.
C. Notify the healthcare provider immediately because the client may
have neutropenic fever.
D. Encourage the client to eat raw fruits and vegetables to increase
vitamin intake.
Answer: C
7.
A client with chronic obstructive pulmonary disease is receiving oxygen
at 2 L/min via nasal cannula. The client becomes increasingly drowsy
and difficult to arouse. Respiratory rate decreases from 20/min to
10/min, and the oxygen saturation is 96%. Which action should the
nurse take?
A. Increase the oxygen flow rate to 6 L/min.
B. Remove the oxygen and leave the client unattended.
C. Assess the client's respiratory status and notify the healthcare
provider immediately.
D. Encourage the client to sleep because rest reduces oxygen
consumption.
Answer: C
