HESI EXIT RN 2025/2026 V3 160 Questions with
Verified Answers/Graded A+.
1. A client who received hemodialysis yesterday is experiencing a blood
pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36
breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal
edema, and an oxygen saturation on room air of 89%. Which action should the
nurse take first? - ANSWER--c. Begin supplemental oxygen.
2. an adult male who fell 20 feet from the roof of this home has multiple
injuries, including a right pneumothorax. Chest tubes were inserted in the
emergency department prior to his transfer to the intensive care unit (ICU). the
nurse notes that the suction control chamber is bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml
of bright red blood is measured in the collection chamber. Which intervention
should the nurse implement? - ANSWER--a. Add sterile water to the suction
control chamber.
3. A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a nasogastric tube to suction and is receiving Lactated
Ringer's solution at 75 mL/hour IV. One hour after admission to the unit, the nurse
notes 300 mL of blood in the suction canister, the client's heart rate is 155
beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the
finding to the surgeon. Which action should the nurse implement first? -
ANSWER--d. Increase the infusion rate of Lactated Ringer's solution.
4. A client with Addison's crisis is admitted for treatment with adrenal cortical
supplementation. Based on the client's admitting diagnosis, which findings require
immediate action by the nurse? (Select all that apply) - ANSWER--Headache and
tremors
,Irregular heart rate pallor and diaphoresis
5. An older client is admitted with fluid volume deficit and dehydration. Which
assessment finding is the best indicator of hydration that the nurse should report to
the healthcare provider? - ANSWER--d. Skin tenting occurs when the client's
forearm is pinched.
6. After an inservice about electronic health record (EHR) security and
safeguarding client information, the nurse observes a colleague going home with
printed copies of client information in a uniform pocket. Which action should the
nurse take? - ANSWER--a. File a detailed incident report with the specific hiring
facility.
7. The nurse is evaluating a tertiary prevention program for clients with
cardiovascular disease implemented in a rural health clinic. Which outcome
indicate the program is effective? - ANSWER--c. Clients who incurred disease
complications promptly received rehabilitation.
8. The nurse is caring for a client with chronic obstructive pulmonary disease
(COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse
observes that the client is having increased shortness of breath with respirations at
23 breaths/minute. Which action should the nurse implement first? - ANSWER--d.
Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
9. Which statement by a client who is 24 hours post-subtotal thyroidectomy
requires an immediate investigation by the nurse? - ANSWER--When I get out of
bed quickly, I feel a little dizzy."
10. An older adult male who is in his early 70's is admitted to the emergency
department because of a COPD exacerbation. This client is struggling to breathe
and the healthcare team is preparing for endotracheal intubation. The spouse's
wife, who is 30 years younger than the client, asks the nurse to stop the procedure
and provide the nurse a copy of the client's living will. Which action should the
nurse take? - ANSWER--b. Notify the healthcare provider of the client's wishes.
, 11. An unlicensed assistive personnel (UAP) is assigned to provide personal
care for a client whose prescribed activity is bedrest with bedside commode use.
The UAP reports to the nurse that the client is so obese that the UAP feels unable
to safely assist the client in transferring from the bed to the bedside commode.
How should the nurse respond? - ANSWER--c. Advice the client to maintain
bedrest so that safety can be ensured.
12. A nurse determines that more than 25% of the students at a middle school
are overweight. The nurse presents the information at the parent-teacher meeting.
What action is most important for the nurse to include in the meeting? -
ANSWER--c. Distribute a shopping list of suggested healthy snack items.
13. After several months of chronic fatigue, morning stiffness, and join pain, a
young adult is diagnosed with rheumatoid arthritis, and the healthcare provider
prescribes prednisone. Which education should the nurse provide the client with
regard to taking prednisone? - ANSWER--c. If sequential doses are missed, notify
the healthcare provider.
14. The psychiatric nurse is caring for clients on an adolescent unit. Which
client requires the nurse's immediate attention? - ANSWER--c. An 18-year-old
client with antisocial behavior who is being yelled at by other clients
15. The nurse caring for a child with mononucleosis can expect the child to
exhibit which symptoms? - ANSWER--b. Ear pain and fever.
16. A client arrives for an annual physical exam and complains of having calf
pain. The client's health history reveals peripheral atrial disease. Which question
should the nurse ask the client about expected finding related to chronic arterial
symptoms? - ANSWER--b. Does the calf pain occur when walking short
distances?
Verified Answers/Graded A+.
1. A client who received hemodialysis yesterday is experiencing a blood
pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36
breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal
edema, and an oxygen saturation on room air of 89%. Which action should the
nurse take first? - ANSWER--c. Begin supplemental oxygen.
2. an adult male who fell 20 feet from the roof of this home has multiple
injuries, including a right pneumothorax. Chest tubes were inserted in the
emergency department prior to his transfer to the intensive care unit (ICU). the
nurse notes that the suction control chamber is bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml
of bright red blood is measured in the collection chamber. Which intervention
should the nurse implement? - ANSWER--a. Add sterile water to the suction
control chamber.
3. A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a nasogastric tube to suction and is receiving Lactated
Ringer's solution at 75 mL/hour IV. One hour after admission to the unit, the nurse
notes 300 mL of blood in the suction canister, the client's heart rate is 155
beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the
finding to the surgeon. Which action should the nurse implement first? -
ANSWER--d. Increase the infusion rate of Lactated Ringer's solution.
4. A client with Addison's crisis is admitted for treatment with adrenal cortical
supplementation. Based on the client's admitting diagnosis, which findings require
immediate action by the nurse? (Select all that apply) - ANSWER--Headache and
tremors
,Irregular heart rate pallor and diaphoresis
5. An older client is admitted with fluid volume deficit and dehydration. Which
assessment finding is the best indicator of hydration that the nurse should report to
the healthcare provider? - ANSWER--d. Skin tenting occurs when the client's
forearm is pinched.
6. After an inservice about electronic health record (EHR) security and
safeguarding client information, the nurse observes a colleague going home with
printed copies of client information in a uniform pocket. Which action should the
nurse take? - ANSWER--a. File a detailed incident report with the specific hiring
facility.
7. The nurse is evaluating a tertiary prevention program for clients with
cardiovascular disease implemented in a rural health clinic. Which outcome
indicate the program is effective? - ANSWER--c. Clients who incurred disease
complications promptly received rehabilitation.
8. The nurse is caring for a client with chronic obstructive pulmonary disease
(COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse
observes that the client is having increased shortness of breath with respirations at
23 breaths/minute. Which action should the nurse implement first? - ANSWER--d.
Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
9. Which statement by a client who is 24 hours post-subtotal thyroidectomy
requires an immediate investigation by the nurse? - ANSWER--When I get out of
bed quickly, I feel a little dizzy."
10. An older adult male who is in his early 70's is admitted to the emergency
department because of a COPD exacerbation. This client is struggling to breathe
and the healthcare team is preparing for endotracheal intubation. The spouse's
wife, who is 30 years younger than the client, asks the nurse to stop the procedure
and provide the nurse a copy of the client's living will. Which action should the
nurse take? - ANSWER--b. Notify the healthcare provider of the client's wishes.
, 11. An unlicensed assistive personnel (UAP) is assigned to provide personal
care for a client whose prescribed activity is bedrest with bedside commode use.
The UAP reports to the nurse that the client is so obese that the UAP feels unable
to safely assist the client in transferring from the bed to the bedside commode.
How should the nurse respond? - ANSWER--c. Advice the client to maintain
bedrest so that safety can be ensured.
12. A nurse determines that more than 25% of the students at a middle school
are overweight. The nurse presents the information at the parent-teacher meeting.
What action is most important for the nurse to include in the meeting? -
ANSWER--c. Distribute a shopping list of suggested healthy snack items.
13. After several months of chronic fatigue, morning stiffness, and join pain, a
young adult is diagnosed with rheumatoid arthritis, and the healthcare provider
prescribes prednisone. Which education should the nurse provide the client with
regard to taking prednisone? - ANSWER--c. If sequential doses are missed, notify
the healthcare provider.
14. The psychiatric nurse is caring for clients on an adolescent unit. Which
client requires the nurse's immediate attention? - ANSWER--c. An 18-year-old
client with antisocial behavior who is being yelled at by other clients
15. The nurse caring for a child with mononucleosis can expect the child to
exhibit which symptoms? - ANSWER--b. Ear pain and fever.
16. A client arrives for an annual physical exam and complains of having calf
pain. The client's health history reveals peripheral atrial disease. Which question
should the nurse ask the client about expected finding related to chronic arterial
symptoms? - ANSWER--b. Does the calf pain occur when walking short
distances?
