HESI Exit RN V4 - Medical Surgical & Pharmacology Integration - Diabetes DKA Warfarin Hyperkalemia Hypoglycemia
HESI Exit RN V4 | High Yield | Priority Nursing Interventions
TABLE OF CONTENTS
1. I. Medical Surgical - Heart Failure Dyspnea Orthopnea PND Crackles Edema Weight Gain BNP Priority Daily Weights Same Time Same Scale Same
Clothes I&O Low Sodium 2 g Fluid Restriction Diuretics Furosemide Monitor Potassium Elevate Legs BNP EF ACE Beta Blocker, COPD Exacerbation
Bronchodilators Albuterol Ipratropium Steroids Prednisone Antibiotics Purulent Oxygen Target 88-92% Low Flow Prevent CO2 Retention Cough Deep
Breathing
2. II. Cardiac Emergency - STEMI Anterior Crushing Substernal Radiating Left Arm Diaphoresis Nausea ST Elevations V1-V4 Priority Aspirin 325 mg
Chewed Oxygen if Hypoxic NTG if No Contraindications Heparin Activate Cath Lab PCI 90 min Door to Balloon Troponin EKG Morphine, Stroke Sudden
Unilateral Weakness Facial Droop Aphasia Last Known Well 1 Hour Within Window Priority Activate Stroke Protocol CT Non-Contrast Rule Out
Hemorrhage NIHSS tPA Alteplase if Ischemic Within 4.5 Hours No Contraindications BP Management Swallow Screen
3. III. Endocrine Diabetes - DKA Polyuria Polydipsia Nausea Vomiting Abdominal Pain Kussmaul Breathing Glucose 450 pH 7.1 Bicarbonate 8 Ketones
Positive Priority IV Fluids NS 0.9% 1 L First Hour Insulin Infusion Regular 0.1 Units/kg/hr After Fluids Monitor Potassium Initially High Then Low Correct
Acidosis I&O, Hyperkalemia K 6.8 Peaked T Waves Priority Calcium Gluconate Chloride Stabilizes Cardiac Membrane Then Insulin Glucose Shifts K Into
Cells Kayexalate Dialysis Stop K Sources EKG, Hypoglycemia Glucose 45 <70 Diaphoresis Confusion Tachycardia Priority Conscious Oral Glucose 15 g
Juice Unconscious D50 IV Glucagon IM Recheck 15 min Rule of 15
4. IV. Pharmacology - Warfarin INR 4.5 Bleeding Gums High Supratherapeutic Priority Hold Warfarin Per Order Vitamin K Injection Assess Bleeding Diet
Drug Interactions PT INR Normal 0.8-1.2 Therapeutic 2-3 Afib DVT, Heparin aPTT Therapeutic 60-80, DVT Calf Pain Swelling Do Not Massage Do Not
Homan's Doppler Ultrasound Anticoagulation Heparin Warfarin DOAC Apixaban Elevation Compression Stockings Early Ambulation After Anticoagulation
5. V. Maternal Newborn - Postpartum Hemorrhage Boggy Uterus Heavy Bleeding Priority Fundal Massage Firm Oxytocin Pitocin Infusion Empty Bladder
Vitals Quantify Blood Loss Check Lacerations Retained Placenta Methylergonovine Misoprostol, Preeclampsia BP 150/95 Proteinuria Headache Visual
Changes Epigastric Pain Severe Features Priority Magnesium Sulfate Prevent Seizures Antihypertensive Labetalol Hydralazine Nifedipine if Severe
>160/110 Delivery Definitive Monitor Reflexes Respirations Urine Output Toxicity Calcium Gluconate Antidote, Newborn Respiratory Distress Cyanosis
Feeding Difficulty Assess Congenital Heart Disease Cyanotic vs Acyanotic Vitals Pulse Ox Pre Post Ductal Murmurs Pulses Capillary Refill
6. VI. Pediatrics - Dehydration Sunken Eyes Decreased Skin Turgor Dry Mucous Membranes Decreased Urine Output Tachycardia Hypotension Mild
3-5% Moderate 6-9% Severe >=10% Management ORS Mild Moderate IV Fluids NS LR Severe, Asthma Exacerbation Wheezing Dyspnea Decreased
Peak Flow First Line SABA Albuterol Nebulizer MDI Spacer Oxygen Steroids Prednisone if Moderate Severe Ipratropium Assess Peak Flow Trigger
Avoidance, Pneumonia Fever Productive Cough Crackles Infiltrate Priority Antibiotics Within 4-6 Hours Blood Cultures First Oxygen Hydration Cough
Deep Breathe Incentive Spirometry Fever Control
7. VII. Mental Health - Major Depressive Disorder Anhedonia Weight Loss Insomnia Suicidal Ideation With Plan Priority Safety 1:1 Observation Remove
Harmful Objects Safety Contract Not Reliable Assess Plan Means Intent SSRI Sertraline Black Box Warning Initial Weeks, Schizophrenia Hearing Voices
Paranoid Delusions Therapeutic Communication Do Not Argue Delusions Acknowledge Feelings Focus Reality Ask Voices Content Safety Assess
Suicidal Homicidal Ideation Medication Adherence Antipsychotic
8. VIII. Critical Care Emergency - Anaphylaxis Bee Sting Dyspnea Wheezing Hypotension Hives Priority Epinephrine 0.3-0.5 mg IM Anterolateral Thigh
Oxygen IV Fluids Antihistamine Diphenhydramine Corticosteroid Monitor Airway, Post-Op Day 1 Abdominal Surgery Decreased Urine Output
Hypotension Tachycardia Dry Mucous Membranes Hypovolemia Third Spacing Bleeding Priority IV Fluids Bolus NS LR I&O Vitals Assess Bleeding Labs
Hgb Hct Notify Provider, CKD Creatinine BUN High Hyperkalemia Edema Diet Low Protein 0.6-0.8 g/kg Low Sodium 2 g Low Potassium Low Phosphorus
Fluid Restriction Monitor I&O Daily Weights
9. IX. Practice Questions - Each Asked Like Real HESI Exit RN V4 Exam
10. X. Answer Key with Detailed Rationales
,HESI EXIT RN V4 - PRACTICE QUESTIONS - EACH QUESTION ASKED LIKE REAL EXAM
Based on HESI Exit RN V4 Blueprint - Medical Surgical Cardiac Endocrine Pharmacology Maternal Newborn Pediatrics Mental Health Critical Care Emergency Fundamentals. High Yield.
1. A client with stroke sudden unilateral weakness, facial droop, aphasia, last known well 1 hour ago. What is priority?
A. Wait and see
B. Stroke - last known well 1 hour ago within window - priority activate stroke protocol, CT non-contrast to rule out hemorrhage, NIHSS, tPA alteplase if ischemic within 4.5
hours no contraindications, blood pressure management, swallow screen
C. No CT
D. Only aspirin
Answer: B
Rationale: Stroke sudden unilateral weakness facial droop aphasia last known well 1 hour within window priority activate stroke protocol CT non-contrast rule out hemorrhage
NIHSS tPA alteplase if ischemic within 4.5 hours no contraindications BP management swallow screen.
2. A client with hyperkalemia potassium 6.8 peaked T waves. What is priority treatment?
A. Only fluids
B. No treatment
C. Give potassium
D. Hyperkalemia K 6.8 peaked T waves - priority calcium gluconate or calcium chloride stabilizes cardiac membrane, then insulin glucose shifts K into cells, kayexalate,
dialysis, stop K sources, EKG monitor
Answer: D
Rationale: Hyperkalemia K 6.8 peaked T waves priority calcium gluconate chloride stabilizes cardiac membrane then insulin glucose shifts K into cells kayexalate dialysis stop
K sources EKG monitor.
3. A client with anaphylaxis after bee sting dyspnea wheezing hypotension hives. What is priority action?
A. Only fluids
B. No epi
C. Give antihistamine only
D. Anaphylaxis dyspnea wheezing hypotension hives - priority epinephrine 0.3-0.5 mg IM anterolateral thigh, oxygen, IV fluids, antihistamine diphenhydramine, corticosteroid,
monitor airway
Answer: D
Rationale: Anaphylaxis dyspnea wheezing hypotension hives priority epinephrine 0.3-0.5 mg IM anterolateral thigh oxygen IV fluids antihistamine diphenhydramine
corticosteroid monitor airway.
4. A client with hyperkalemia potassium 6.8 peaked T waves. What is priority treatment?
A. No treatment
B. Only fluids
C. Give potassium
D. Hyperkalemia K 6.8 peaked T waves - priority calcium gluconate or calcium chloride stabilizes cardiac membrane, then insulin glucose shifts K into cells, kayexalate,
dialysis, stop K sources, EKG monitor
Answer: D
Rationale: Hyperkalemia K 6.8 peaked T waves priority calcium gluconate chloride stabilizes cardiac membrane then insulin glucose shifts K into cells kayexalate dialysis stop
K sources EKG monitor.
5. A client with stroke sudden unilateral weakness, facial droop, aphasia, last known well 1 hour ago. What is priority?
A. Stroke - last known well 1 hour ago within window - priority activate stroke protocol, CT non-contrast to rule out hemorrhage, NIHSS, tPA alteplase if ischemic within 4.5
hours no contraindications, blood pressure management, swallow screen
B. Only aspirin
C. No CT
D. Wait and see
Answer: A
Rationale: Stroke sudden unilateral weakness facial droop aphasia last known well 1 hour within window priority activate stroke protocol CT non-contrast rule out hemorrhage
NIHSS tPA alteplase if ischemic within 4.5 hours no contraindications BP management swallow screen.
6. A client with hyperkalemia potassium 6.8 peaked T waves. What is priority treatment?
A. Hyperkalemia K 6.8 peaked T waves - priority calcium gluconate or calcium chloride stabilizes cardiac membrane, then insulin glucose shifts K into cells, kayexalate,
dialysis, stop K sources, EKG monitor
B. No treatment
C. Only fluids
D. Give potassium
Answer: A
Rationale: Hyperkalemia K 6.8 peaked T waves priority calcium gluconate chloride stabilizes cardiac membrane then insulin glucose shifts K into cells kayexalate dialysis stop
K sources EKG monitor.
7. A client with schizophrenia hearing voices, paranoid delusions. What is therapeutic communication?
A. Schizophrenia hearing voices paranoid delusions - therapeutic communication: do not argue delusions, acknowledge feelings, focus on reality, ask about voices content
safety, assess suicidal homicidal ideation, medication adherence antipsychotic
B. Reinforce delusions
C. No communication
D. Argue with delusions
Answer: A
Rationale: Schizophrenia hearing voices paranoid delusions therapeutic communication do not argue delusions acknowledge feelings focus reality ask voices content safety
assess suicidal homicidal ideation medication adherence antipsychotic.
8. A client with diabetic ketoacidosis polyuria polydipsia nausea vomiting abdominal pain Kussmaul breathing glucose 450 pH 7.1 bicarbonate 8 ketones positive.
What is priority nursing action?
A. Give bicarbonate
,B. DKA priority IV fluids NS 0.9% 1 L first hour, insulin infusion regular insulin 0.1 units/kg/hr after fluids, monitor potassium initially high then low, correct acidosis, monitor
glucose electrolytes I&O
C. No fluids
D. Only oral meds
Answer: B
Rationale: DKA priority IV fluids NS 0.9% 1 L first hour insulin infusion regular 0.1 units/kg/hr after fluids monitor potassium initially high then low correct acidosis monitor
glucose electrolytes I&O.
9. A client with anaphylaxis after bee sting dyspnea wheezing hypotension hives. What is priority action?
A. Anaphylaxis dyspnea wheezing hypotension hives - priority epinephrine 0.3-0.5 mg IM anterolateral thigh, oxygen, IV fluids, antihistamine diphenhydramine, corticosteroid,
monitor airway
B. Give antihistamine only
C. No epi
D. Only fluids
Answer: A
Rationale: Anaphylaxis dyspnea wheezing hypotension hives priority epinephrine 0.3-0.5 mg IM anterolateral thigh oxygen IV fluids antihistamine diphenhydramine
corticosteroid monitor airway.
10. A client with anaphylaxis after bee sting dyspnea wheezing hypotension hives. What is priority action?
A. No epi
B. Only fluids
C. Give antihistamine only
D. Anaphylaxis dyspnea wheezing hypotension hives - priority epinephrine 0.3-0.5 mg IM anterolateral thigh, oxygen, IV fluids, antihistamine diphenhydramine, corticosteroid,
monitor airway
Answer: D
Rationale: Anaphylaxis dyspnea wheezing hypotension hives priority epinephrine 0.3-0.5 mg IM anterolateral thigh oxygen IV fluids antihistamine diphenhydramine
corticosteroid monitor airway.
11. A client with hypoglycemia glucose 45 diaphoresis confusion tachycardia. What is priority action?
A. Give insulin
B. Only fluids
C. No glucose
D. Hypoglycemia glucose 45 <70 diaphoresis confusion tachycardia - priority if conscious oral glucose 15 g juice, if unconscious D50 IV or glucagon IM, recheck 15 min, rule of
15
Answer: D
Rationale: Hypoglycemia glucose 45 <70 diaphoresis confusion tachycardia priority if conscious oral glucose 15 g juice if unconscious D50 IV glucagon IM recheck 15 min
rule of 15.
12. A client with chest pain crushing substernal radiating left arm diaphoresis nausea ST elevations V1-V4. What is priority action?
A. Only reassure
B. Give antacid
C. No aspirin
D. STEMI anterior - priority aspirin 325 mg chewed, oxygen if hypoxic, nitroglycerin if no contraindications hypotension Viagra, heparin, activate cath lab PCI within 90 min door
to balloon, troponin, EKG, morphine if pain
Answer: D
Rationale: STEMI anterior crushing substernal radiating left arm diaphoresis nausea ST elevations V1-V4 priority aspirin 325 mg chewed oxygen if hypoxic NTG if no
contraindications heparin activate cath lab PCI 90 min troponin EKG morphine if pain.
13. A client with asthma exacerbation wheezing dyspnea decreased peak flow. What is first line treatment?
A. Only oxygen
B. Asthma exacerbation wheezing dyspnea decreased peak flow - first line SABA albuterol nebulizer MDI spacer, oxygen, steroids prednisone if moderate severe, ipratropium,
assess peak flow, trigger avoidance
C. Only steroids
D. No bronchodilator
Answer: B
Rationale: Asthma exacerbation wheezing dyspnea decreased peak flow first line SABA albuterol nebulizer MDI spacer oxygen steroids prednisone if moderate severe
ipratropium assess peak flow trigger avoidance.
14. A client on warfarin with INR 4.5, bleeding gums. What is priority action?
A. Give more warfarin
B. No action
C. Give vitamin K injection and hold warfarin per order, assess bleeding, check diet, drug interactions, PT INR
D. Only fluids
Answer: C
Rationale: Warfarin INR 4.5 bleeding gums high supratherapeutic priority hold warfarin per order vitamin K injection assess bleeding diet drug interactions PT INR normal
0.8-1.2 therapeutic 2-3 Afib DVT.
15. A client post-op day 1 after abdominal surgery with decreased urine output, hypotension, tachycardia, dry mucous membranes. What is priority?
A. Post-op decreased urine output hypotension tachycardia dry mucous membranes - hypovolemia third spacing bleeding - priority IV fluids bolus NS LR, I&O, vital signs,
assess bleeding, check labs Hgb Hct, notify provider
B. Only pain meds
C. Give diuretic
D. No fluids
Answer: A
Rationale: Post-op decreased urine hypotension tachycardia dry mucous membranes hypovolemia third spacing bleeding priority IV fluids bolus NS LR I&O vitals assess
bleeding labs Hgb Hct notify provider.
16. A client with deep vein thrombosis calf pain swelling positive Homan's? Actually Homan's not reliable. What is management?
, A. Massage calf
B. Only rest
C. DVT calf pain swelling - do not massage, do not do Homan's, Doppler ultrasound, anticoagulation heparin warfarin DOAC apixaban, elevation, compression stockings later,
early ambulation after anticoagulation
D. No anticoagulation
Answer: C
Rationale: DVT calf pain swelling do not massage do not Homan's Doppler ultrasound anticoagulation heparin warfarin DOAC apixaban elevation compression stockings later
early ambulation after anticoagulation.
17. A client with chronic kidney disease creatinine high BUN high hyperkalemia edema. What is priority diet teaching?
A. High potassium diet
B. High protein
C. No diet
D. CKD creatinine BUN high hyperkalemia edema - priority diet low protein 0.6-0.8 g/kg, low sodium 2 g, low potassium, low phosphorus, fluid restriction, monitor I&O daily
weights
Answer: D
Rationale: CKD creatinine BUN high hyperkalemia edema diet low protein 0.6-0.8 g/kg low sodium 2 g low potassium low phosphorus fluid restriction monitor I&O daily
weights.
18. A client with stroke sudden unilateral weakness, facial droop, aphasia, last known well 1 hour ago. What is priority?
A. No CT
B. Only aspirin
C. Wait and see
D. Stroke - last known well 1 hour ago within window - priority activate stroke protocol, CT non-contrast to rule out hemorrhage, NIHSS, tPA alteplase if ischemic within 4.5
hours no contraindications, blood pressure management, swallow screen
Answer: D
Rationale: Stroke sudden unilateral weakness facial droop aphasia last known well 1 hour within window priority activate stroke protocol CT non-contrast rule out hemorrhage
NIHSS tPA alteplase if ischemic within 4.5 hours no contraindications BP management swallow screen.
19. A client with hyperkalemia potassium 6.8 peaked T waves. What is priority treatment?
A. Only fluids
B. Hyperkalemia K 6.8 peaked T waves - priority calcium gluconate or calcium chloride stabilizes cardiac membrane, then insulin glucose shifts K into cells, kayexalate,
dialysis, stop K sources, EKG monitor
C. Give potassium
D. No treatment
Answer: B
Rationale: Hyperkalemia K 6.8 peaked T waves priority calcium gluconate chloride stabilizes cardiac membrane then insulin glucose shifts K into cells kayexalate dialysis stop
K sources EKG monitor.
20. A newborn with respiratory distress, cyanosis, difficulty feeding. What is priority assessment for congenital heart disease?
A. Only weight
B. Newborn respiratory distress cyanosis difficulty feeding - assess for congenital heart disease - cyanotic vs acyanotic, vitals, pulse oximetry pre and post ductal, murmurs,
pulses, capillary refill, feeding difficulty
C. Only temp
D. No assessment
Answer: B
Rationale: Newborn respiratory distress cyanosis feeding difficulty assess congenital heart disease cyanotic vs acyanotic vitals pulse ox pre post ductal murmurs pulses
capillary refill feeding difficulty.
21. A client with schizophrenia hearing voices, paranoid delusions. What is therapeutic communication?
A. No communication
B. Reinforce delusions
C. Argue with delusions
D. Schizophrenia hearing voices paranoid delusions - therapeutic communication: do not argue delusions, acknowledge feelings, focus on reality, ask about voices content
safety, assess suicidal homicidal ideation, medication adherence antipsychotic
Answer: D
Rationale: Schizophrenia hearing voices paranoid delusions therapeutic communication do not argue delusions acknowledge feelings focus reality ask voices content safety
assess suicidal homicidal ideation medication adherence antipsychotic.
22. A client with pneumonia fever productive cough crackles chest X-ray infiltrate. What is priority nursing intervention?
A. Only rest
B. Only oxygen
C. No antibiotics
D. Pneumonia fever productive cough crackles infiltrate - priority antibiotics within 4-6 hours blood cultures first, oxygen, hydration, cough deep breathe incentive spirometry,
fever control
Answer: D
Rationale: Pneumonia fever productive cough crackles infiltrate priority antibiotics within 4-6 hours blood cultures first oxygen hydration cough deep breathe incentive
spirometry fever control.
23. A client with major depressive disorder anhedonia weight loss insomnia suicidal ideation with plan. What is priority nursing action?
A. Leave alone
B. Only reassure
C. MDD anhedonia weight loss insomnia suicidal ideation with plan - priority safety - 1:1 observation, remove harmful objects, safety contract no suicide contract not reliable,
assess plan means intent, SSRI sertraline but black box warning initial weeks
D. No safety
Answer: C
HESI Exit RN V4 | High Yield | Priority Nursing Interventions
TABLE OF CONTENTS
1. I. Medical Surgical - Heart Failure Dyspnea Orthopnea PND Crackles Edema Weight Gain BNP Priority Daily Weights Same Time Same Scale Same
Clothes I&O Low Sodium 2 g Fluid Restriction Diuretics Furosemide Monitor Potassium Elevate Legs BNP EF ACE Beta Blocker, COPD Exacerbation
Bronchodilators Albuterol Ipratropium Steroids Prednisone Antibiotics Purulent Oxygen Target 88-92% Low Flow Prevent CO2 Retention Cough Deep
Breathing
2. II. Cardiac Emergency - STEMI Anterior Crushing Substernal Radiating Left Arm Diaphoresis Nausea ST Elevations V1-V4 Priority Aspirin 325 mg
Chewed Oxygen if Hypoxic NTG if No Contraindications Heparin Activate Cath Lab PCI 90 min Door to Balloon Troponin EKG Morphine, Stroke Sudden
Unilateral Weakness Facial Droop Aphasia Last Known Well 1 Hour Within Window Priority Activate Stroke Protocol CT Non-Contrast Rule Out
Hemorrhage NIHSS tPA Alteplase if Ischemic Within 4.5 Hours No Contraindications BP Management Swallow Screen
3. III. Endocrine Diabetes - DKA Polyuria Polydipsia Nausea Vomiting Abdominal Pain Kussmaul Breathing Glucose 450 pH 7.1 Bicarbonate 8 Ketones
Positive Priority IV Fluids NS 0.9% 1 L First Hour Insulin Infusion Regular 0.1 Units/kg/hr After Fluids Monitor Potassium Initially High Then Low Correct
Acidosis I&O, Hyperkalemia K 6.8 Peaked T Waves Priority Calcium Gluconate Chloride Stabilizes Cardiac Membrane Then Insulin Glucose Shifts K Into
Cells Kayexalate Dialysis Stop K Sources EKG, Hypoglycemia Glucose 45 <70 Diaphoresis Confusion Tachycardia Priority Conscious Oral Glucose 15 g
Juice Unconscious D50 IV Glucagon IM Recheck 15 min Rule of 15
4. IV. Pharmacology - Warfarin INR 4.5 Bleeding Gums High Supratherapeutic Priority Hold Warfarin Per Order Vitamin K Injection Assess Bleeding Diet
Drug Interactions PT INR Normal 0.8-1.2 Therapeutic 2-3 Afib DVT, Heparin aPTT Therapeutic 60-80, DVT Calf Pain Swelling Do Not Massage Do Not
Homan's Doppler Ultrasound Anticoagulation Heparin Warfarin DOAC Apixaban Elevation Compression Stockings Early Ambulation After Anticoagulation
5. V. Maternal Newborn - Postpartum Hemorrhage Boggy Uterus Heavy Bleeding Priority Fundal Massage Firm Oxytocin Pitocin Infusion Empty Bladder
Vitals Quantify Blood Loss Check Lacerations Retained Placenta Methylergonovine Misoprostol, Preeclampsia BP 150/95 Proteinuria Headache Visual
Changes Epigastric Pain Severe Features Priority Magnesium Sulfate Prevent Seizures Antihypertensive Labetalol Hydralazine Nifedipine if Severe
>160/110 Delivery Definitive Monitor Reflexes Respirations Urine Output Toxicity Calcium Gluconate Antidote, Newborn Respiratory Distress Cyanosis
Feeding Difficulty Assess Congenital Heart Disease Cyanotic vs Acyanotic Vitals Pulse Ox Pre Post Ductal Murmurs Pulses Capillary Refill
6. VI. Pediatrics - Dehydration Sunken Eyes Decreased Skin Turgor Dry Mucous Membranes Decreased Urine Output Tachycardia Hypotension Mild
3-5% Moderate 6-9% Severe >=10% Management ORS Mild Moderate IV Fluids NS LR Severe, Asthma Exacerbation Wheezing Dyspnea Decreased
Peak Flow First Line SABA Albuterol Nebulizer MDI Spacer Oxygen Steroids Prednisone if Moderate Severe Ipratropium Assess Peak Flow Trigger
Avoidance, Pneumonia Fever Productive Cough Crackles Infiltrate Priority Antibiotics Within 4-6 Hours Blood Cultures First Oxygen Hydration Cough
Deep Breathe Incentive Spirometry Fever Control
7. VII. Mental Health - Major Depressive Disorder Anhedonia Weight Loss Insomnia Suicidal Ideation With Plan Priority Safety 1:1 Observation Remove
Harmful Objects Safety Contract Not Reliable Assess Plan Means Intent SSRI Sertraline Black Box Warning Initial Weeks, Schizophrenia Hearing Voices
Paranoid Delusions Therapeutic Communication Do Not Argue Delusions Acknowledge Feelings Focus Reality Ask Voices Content Safety Assess
Suicidal Homicidal Ideation Medication Adherence Antipsychotic
8. VIII. Critical Care Emergency - Anaphylaxis Bee Sting Dyspnea Wheezing Hypotension Hives Priority Epinephrine 0.3-0.5 mg IM Anterolateral Thigh
Oxygen IV Fluids Antihistamine Diphenhydramine Corticosteroid Monitor Airway, Post-Op Day 1 Abdominal Surgery Decreased Urine Output
Hypotension Tachycardia Dry Mucous Membranes Hypovolemia Third Spacing Bleeding Priority IV Fluids Bolus NS LR I&O Vitals Assess Bleeding Labs
Hgb Hct Notify Provider, CKD Creatinine BUN High Hyperkalemia Edema Diet Low Protein 0.6-0.8 g/kg Low Sodium 2 g Low Potassium Low Phosphorus
Fluid Restriction Monitor I&O Daily Weights
9. IX. Practice Questions - Each Asked Like Real HESI Exit RN V4 Exam
10. X. Answer Key with Detailed Rationales
,HESI EXIT RN V4 - PRACTICE QUESTIONS - EACH QUESTION ASKED LIKE REAL EXAM
Based on HESI Exit RN V4 Blueprint - Medical Surgical Cardiac Endocrine Pharmacology Maternal Newborn Pediatrics Mental Health Critical Care Emergency Fundamentals. High Yield.
1. A client with stroke sudden unilateral weakness, facial droop, aphasia, last known well 1 hour ago. What is priority?
A. Wait and see
B. Stroke - last known well 1 hour ago within window - priority activate stroke protocol, CT non-contrast to rule out hemorrhage, NIHSS, tPA alteplase if ischemic within 4.5
hours no contraindications, blood pressure management, swallow screen
C. No CT
D. Only aspirin
Answer: B
Rationale: Stroke sudden unilateral weakness facial droop aphasia last known well 1 hour within window priority activate stroke protocol CT non-contrast rule out hemorrhage
NIHSS tPA alteplase if ischemic within 4.5 hours no contraindications BP management swallow screen.
2. A client with hyperkalemia potassium 6.8 peaked T waves. What is priority treatment?
A. Only fluids
B. No treatment
C. Give potassium
D. Hyperkalemia K 6.8 peaked T waves - priority calcium gluconate or calcium chloride stabilizes cardiac membrane, then insulin glucose shifts K into cells, kayexalate,
dialysis, stop K sources, EKG monitor
Answer: D
Rationale: Hyperkalemia K 6.8 peaked T waves priority calcium gluconate chloride stabilizes cardiac membrane then insulin glucose shifts K into cells kayexalate dialysis stop
K sources EKG monitor.
3. A client with anaphylaxis after bee sting dyspnea wheezing hypotension hives. What is priority action?
A. Only fluids
B. No epi
C. Give antihistamine only
D. Anaphylaxis dyspnea wheezing hypotension hives - priority epinephrine 0.3-0.5 mg IM anterolateral thigh, oxygen, IV fluids, antihistamine diphenhydramine, corticosteroid,
monitor airway
Answer: D
Rationale: Anaphylaxis dyspnea wheezing hypotension hives priority epinephrine 0.3-0.5 mg IM anterolateral thigh oxygen IV fluids antihistamine diphenhydramine
corticosteroid monitor airway.
4. A client with hyperkalemia potassium 6.8 peaked T waves. What is priority treatment?
A. No treatment
B. Only fluids
C. Give potassium
D. Hyperkalemia K 6.8 peaked T waves - priority calcium gluconate or calcium chloride stabilizes cardiac membrane, then insulin glucose shifts K into cells, kayexalate,
dialysis, stop K sources, EKG monitor
Answer: D
Rationale: Hyperkalemia K 6.8 peaked T waves priority calcium gluconate chloride stabilizes cardiac membrane then insulin glucose shifts K into cells kayexalate dialysis stop
K sources EKG monitor.
5. A client with stroke sudden unilateral weakness, facial droop, aphasia, last known well 1 hour ago. What is priority?
A. Stroke - last known well 1 hour ago within window - priority activate stroke protocol, CT non-contrast to rule out hemorrhage, NIHSS, tPA alteplase if ischemic within 4.5
hours no contraindications, blood pressure management, swallow screen
B. Only aspirin
C. No CT
D. Wait and see
Answer: A
Rationale: Stroke sudden unilateral weakness facial droop aphasia last known well 1 hour within window priority activate stroke protocol CT non-contrast rule out hemorrhage
NIHSS tPA alteplase if ischemic within 4.5 hours no contraindications BP management swallow screen.
6. A client with hyperkalemia potassium 6.8 peaked T waves. What is priority treatment?
A. Hyperkalemia K 6.8 peaked T waves - priority calcium gluconate or calcium chloride stabilizes cardiac membrane, then insulin glucose shifts K into cells, kayexalate,
dialysis, stop K sources, EKG monitor
B. No treatment
C. Only fluids
D. Give potassium
Answer: A
Rationale: Hyperkalemia K 6.8 peaked T waves priority calcium gluconate chloride stabilizes cardiac membrane then insulin glucose shifts K into cells kayexalate dialysis stop
K sources EKG monitor.
7. A client with schizophrenia hearing voices, paranoid delusions. What is therapeutic communication?
A. Schizophrenia hearing voices paranoid delusions - therapeutic communication: do not argue delusions, acknowledge feelings, focus on reality, ask about voices content
safety, assess suicidal homicidal ideation, medication adherence antipsychotic
B. Reinforce delusions
C. No communication
D. Argue with delusions
Answer: A
Rationale: Schizophrenia hearing voices paranoid delusions therapeutic communication do not argue delusions acknowledge feelings focus reality ask voices content safety
assess suicidal homicidal ideation medication adherence antipsychotic.
8. A client with diabetic ketoacidosis polyuria polydipsia nausea vomiting abdominal pain Kussmaul breathing glucose 450 pH 7.1 bicarbonate 8 ketones positive.
What is priority nursing action?
A. Give bicarbonate
,B. DKA priority IV fluids NS 0.9% 1 L first hour, insulin infusion regular insulin 0.1 units/kg/hr after fluids, monitor potassium initially high then low, correct acidosis, monitor
glucose electrolytes I&O
C. No fluids
D. Only oral meds
Answer: B
Rationale: DKA priority IV fluids NS 0.9% 1 L first hour insulin infusion regular 0.1 units/kg/hr after fluids monitor potassium initially high then low correct acidosis monitor
glucose electrolytes I&O.
9. A client with anaphylaxis after bee sting dyspnea wheezing hypotension hives. What is priority action?
A. Anaphylaxis dyspnea wheezing hypotension hives - priority epinephrine 0.3-0.5 mg IM anterolateral thigh, oxygen, IV fluids, antihistamine diphenhydramine, corticosteroid,
monitor airway
B. Give antihistamine only
C. No epi
D. Only fluids
Answer: A
Rationale: Anaphylaxis dyspnea wheezing hypotension hives priority epinephrine 0.3-0.5 mg IM anterolateral thigh oxygen IV fluids antihistamine diphenhydramine
corticosteroid monitor airway.
10. A client with anaphylaxis after bee sting dyspnea wheezing hypotension hives. What is priority action?
A. No epi
B. Only fluids
C. Give antihistamine only
D. Anaphylaxis dyspnea wheezing hypotension hives - priority epinephrine 0.3-0.5 mg IM anterolateral thigh, oxygen, IV fluids, antihistamine diphenhydramine, corticosteroid,
monitor airway
Answer: D
Rationale: Anaphylaxis dyspnea wheezing hypotension hives priority epinephrine 0.3-0.5 mg IM anterolateral thigh oxygen IV fluids antihistamine diphenhydramine
corticosteroid monitor airway.
11. A client with hypoglycemia glucose 45 diaphoresis confusion tachycardia. What is priority action?
A. Give insulin
B. Only fluids
C. No glucose
D. Hypoglycemia glucose 45 <70 diaphoresis confusion tachycardia - priority if conscious oral glucose 15 g juice, if unconscious D50 IV or glucagon IM, recheck 15 min, rule of
15
Answer: D
Rationale: Hypoglycemia glucose 45 <70 diaphoresis confusion tachycardia priority if conscious oral glucose 15 g juice if unconscious D50 IV glucagon IM recheck 15 min
rule of 15.
12. A client with chest pain crushing substernal radiating left arm diaphoresis nausea ST elevations V1-V4. What is priority action?
A. Only reassure
B. Give antacid
C. No aspirin
D. STEMI anterior - priority aspirin 325 mg chewed, oxygen if hypoxic, nitroglycerin if no contraindications hypotension Viagra, heparin, activate cath lab PCI within 90 min door
to balloon, troponin, EKG, morphine if pain
Answer: D
Rationale: STEMI anterior crushing substernal radiating left arm diaphoresis nausea ST elevations V1-V4 priority aspirin 325 mg chewed oxygen if hypoxic NTG if no
contraindications heparin activate cath lab PCI 90 min troponin EKG morphine if pain.
13. A client with asthma exacerbation wheezing dyspnea decreased peak flow. What is first line treatment?
A. Only oxygen
B. Asthma exacerbation wheezing dyspnea decreased peak flow - first line SABA albuterol nebulizer MDI spacer, oxygen, steroids prednisone if moderate severe, ipratropium,
assess peak flow, trigger avoidance
C. Only steroids
D. No bronchodilator
Answer: B
Rationale: Asthma exacerbation wheezing dyspnea decreased peak flow first line SABA albuterol nebulizer MDI spacer oxygen steroids prednisone if moderate severe
ipratropium assess peak flow trigger avoidance.
14. A client on warfarin with INR 4.5, bleeding gums. What is priority action?
A. Give more warfarin
B. No action
C. Give vitamin K injection and hold warfarin per order, assess bleeding, check diet, drug interactions, PT INR
D. Only fluids
Answer: C
Rationale: Warfarin INR 4.5 bleeding gums high supratherapeutic priority hold warfarin per order vitamin K injection assess bleeding diet drug interactions PT INR normal
0.8-1.2 therapeutic 2-3 Afib DVT.
15. A client post-op day 1 after abdominal surgery with decreased urine output, hypotension, tachycardia, dry mucous membranes. What is priority?
A. Post-op decreased urine output hypotension tachycardia dry mucous membranes - hypovolemia third spacing bleeding - priority IV fluids bolus NS LR, I&O, vital signs,
assess bleeding, check labs Hgb Hct, notify provider
B. Only pain meds
C. Give diuretic
D. No fluids
Answer: A
Rationale: Post-op decreased urine hypotension tachycardia dry mucous membranes hypovolemia third spacing bleeding priority IV fluids bolus NS LR I&O vitals assess
bleeding labs Hgb Hct notify provider.
16. A client with deep vein thrombosis calf pain swelling positive Homan's? Actually Homan's not reliable. What is management?
, A. Massage calf
B. Only rest
C. DVT calf pain swelling - do not massage, do not do Homan's, Doppler ultrasound, anticoagulation heparin warfarin DOAC apixaban, elevation, compression stockings later,
early ambulation after anticoagulation
D. No anticoagulation
Answer: C
Rationale: DVT calf pain swelling do not massage do not Homan's Doppler ultrasound anticoagulation heparin warfarin DOAC apixaban elevation compression stockings later
early ambulation after anticoagulation.
17. A client with chronic kidney disease creatinine high BUN high hyperkalemia edema. What is priority diet teaching?
A. High potassium diet
B. High protein
C. No diet
D. CKD creatinine BUN high hyperkalemia edema - priority diet low protein 0.6-0.8 g/kg, low sodium 2 g, low potassium, low phosphorus, fluid restriction, monitor I&O daily
weights
Answer: D
Rationale: CKD creatinine BUN high hyperkalemia edema diet low protein 0.6-0.8 g/kg low sodium 2 g low potassium low phosphorus fluid restriction monitor I&O daily
weights.
18. A client with stroke sudden unilateral weakness, facial droop, aphasia, last known well 1 hour ago. What is priority?
A. No CT
B. Only aspirin
C. Wait and see
D. Stroke - last known well 1 hour ago within window - priority activate stroke protocol, CT non-contrast to rule out hemorrhage, NIHSS, tPA alteplase if ischemic within 4.5
hours no contraindications, blood pressure management, swallow screen
Answer: D
Rationale: Stroke sudden unilateral weakness facial droop aphasia last known well 1 hour within window priority activate stroke protocol CT non-contrast rule out hemorrhage
NIHSS tPA alteplase if ischemic within 4.5 hours no contraindications BP management swallow screen.
19. A client with hyperkalemia potassium 6.8 peaked T waves. What is priority treatment?
A. Only fluids
B. Hyperkalemia K 6.8 peaked T waves - priority calcium gluconate or calcium chloride stabilizes cardiac membrane, then insulin glucose shifts K into cells, kayexalate,
dialysis, stop K sources, EKG monitor
C. Give potassium
D. No treatment
Answer: B
Rationale: Hyperkalemia K 6.8 peaked T waves priority calcium gluconate chloride stabilizes cardiac membrane then insulin glucose shifts K into cells kayexalate dialysis stop
K sources EKG monitor.
20. A newborn with respiratory distress, cyanosis, difficulty feeding. What is priority assessment for congenital heart disease?
A. Only weight
B. Newborn respiratory distress cyanosis difficulty feeding - assess for congenital heart disease - cyanotic vs acyanotic, vitals, pulse oximetry pre and post ductal, murmurs,
pulses, capillary refill, feeding difficulty
C. Only temp
D. No assessment
Answer: B
Rationale: Newborn respiratory distress cyanosis feeding difficulty assess congenital heart disease cyanotic vs acyanotic vitals pulse ox pre post ductal murmurs pulses
capillary refill feeding difficulty.
21. A client with schizophrenia hearing voices, paranoid delusions. What is therapeutic communication?
A. No communication
B. Reinforce delusions
C. Argue with delusions
D. Schizophrenia hearing voices paranoid delusions - therapeutic communication: do not argue delusions, acknowledge feelings, focus on reality, ask about voices content
safety, assess suicidal homicidal ideation, medication adherence antipsychotic
Answer: D
Rationale: Schizophrenia hearing voices paranoid delusions therapeutic communication do not argue delusions acknowledge feelings focus reality ask voices content safety
assess suicidal homicidal ideation medication adherence antipsychotic.
22. A client with pneumonia fever productive cough crackles chest X-ray infiltrate. What is priority nursing intervention?
A. Only rest
B. Only oxygen
C. No antibiotics
D. Pneumonia fever productive cough crackles infiltrate - priority antibiotics within 4-6 hours blood cultures first, oxygen, hydration, cough deep breathe incentive spirometry,
fever control
Answer: D
Rationale: Pneumonia fever productive cough crackles infiltrate priority antibiotics within 4-6 hours blood cultures first oxygen hydration cough deep breathe incentive
spirometry fever control.
23. A client with major depressive disorder anhedonia weight loss insomnia suicidal ideation with plan. What is priority nursing action?
A. Leave alone
B. Only reassure
C. MDD anhedonia weight loss insomnia suicidal ideation with plan - priority safety - 1:1 observation, remove harmful objects, safety contract no suicide contract not reliable,
assess plan means intent, SSRI sertraline but black box warning initial weeks
D. No safety
Answer: C
