HESI RN Exit Exam 160 Questions & Answers Graded A 2025

1. The nurse is completing the admission assessment of a 3-year-old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)? A. Tachycardia and tachypnea B. Sluggish and unequal pupillary responses C. Increased head circumference and bulging fontanels D. Blood pressure fluctuations and syncope - B. Sluggish and unequal pupillary responses 2. A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum amylase. Which additional information is the client most likely to report to the nurse? A. Abdominal pain decreases when lying supine B. Pain lasts an hour and leaves the abdomen tender C. Right upper quadrant pain refers to right scapula D. Drinks alcohol until intoxicated at least twice weekly. - A. Abdominal pain decreases when lying supine 3. A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? A. Instructions about how much fluid the child should drink daily. B. Signs of addiction to opioid pain medications C. Information about non-pharmaceutical pain relief measures D. Referral for social services for the child and family - A. Instructions about how much fluid the child should drink daily 4. To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select the location on the image with a red dot). - I placed the red dot on the base of the neck on the right side 5. After receiving report on an inpatient acute care unit, which client should the nurse assess first? A. The client with an obstruction of the large intestine who is experiencing abdominal distention B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity HESI RN Exit Exam 160 Questions & Answers Graded A 2025 - D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity 6. A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base imbalance? A. Respiratory acidosis B. Metabolic alkalosis C. Metabolic acidosis D. Respiratory alkalosis - D. Respiratory alkalosis 7. A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the nurse should ensure that the client's bed is in which position? A. Supine B. supine; feet elevated higher than head C. supine; head elevated higher than feet D. Fowlers - Fowlers 8. The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading? (Select all the apply) A. Frequent syncope B. Occasional nocturia C. Flat affect D. Blurred vision E. Frequent drooling - A. Frequent syncope - C. Flat affect - D. Blurred vision 9. While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? A. Serum albumin B. Culture for sensitive organisms C. Serum blood glucose level D. Creatinine level - B. Culture for sensitive organisms 10. A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to the child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. Which action should the nurse take? A. Develop a water safety teaching plan for the family B. Ask the older brother how he felt during the incident C. Tell the older brother that he seems depressed D. Commend the older brother for his heroic actions - B. Ask the older brother how he felt during the incident 11. A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take? A. Encourage the client to use cooler water and apply calamine lotion after soaking B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief C. Suggest that the client take brief showers and apply oil-based lotion after showering D. Explain that the symptoms are caused by liver damage and cannot be relieved - A. Encourage the client to use cooler water and apply calamine lotion after soaking 12. An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and heart failure (HF) arrives in the Emergency Department (ED) in respiratory distress. The healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should the nurse expected in the client with acute HF? A. Increased cardiac contractility B. Reduced preload C. Relaxed vascular tone D. Decreased afterload - B. Reduced preload 13. Which intervention should the nurse include in the plan of care for a child with tetanus? A. Encourage coughing and deep breathing B. Minimize the amount of stimuli in the room C. Reposition from side to side every hour D. Open window shades to provide natural light - B. Minimize the amount of stimuli in the room 14. An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis? A. Ate an extra peanut butter sandwich before gym class B. incorrectly administered too much insulin C. Had a cold and ear infection for the past two days D. Skipped eating lunch - C. Had a cold and ear infection for the past two days 15. A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement? A. The impending signs of death should be documented B. The client's status should be conveyed to the chaplain C. The client's need for pain medication should be determined D. The nurse manager should be updated on the client's status - C. The client's need for pain medication should be determined 16. Which self care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus? A. Self-injection techniques B. Blood glucose monitoring C. Diabetic diet meal planning D. A realistic exercise plan - B. Blood glucose monitoring 17. A client who gave birth 48 hours ago has decided to bottle feed the infant. During the assessment, the nurse observes that both breasts are swollen, warm, and tender on palpation. Which instruction should the nurse provide? A. Apply ice to the breasts for comfort B. Wear a loose-fitting bra during the day to prevent nipple irritation C. Run warm water over breasts D. Express small amounts of milk from the breasts to relieve pressure - A. Apply ice to the breasts for comfort 18. The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply) A. Avoid range of motion exercises B. Use a residual limb shrinker C. Apply alcohol to the stump after bathing D. Inspect skin for redness E. Wash the stump with soap and water - B. Use a residual limb shrinker - D. Inspect skin for redness - E. Wash the stump with soap and water 19. A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain, and vomiting that occurs after ingesting of milk products arrives to the clinic accompanied by the parents. Which type of testing should the nurse provide education to the toddler's family about? A. Serum immunoglobulin E (IgE) B. Intradermal test C. Atopy patch test D. Placebo-controlled food challenge - A. Serum immunoglobulin E (IgE) 20. A client who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about the procedure. In preparing the client for the procedure, which intervention has the highest priority? A. Allow client to gargle with warm salt water B. Administer a sedative to alleviate anxiety C. Instruct client to write down the questions D. Deny client's request for a midnight snack - C. Instruct client to write down the questions 21. The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse? A. Notify the nurse when the transfusion has finished, so further client assessment can be done B. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete C. Monitor the client carefully for the next three hours and report the onset of a reaction immediately D. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion - B. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete 22. The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the plan of care? A. Assess warmth of extremities B. Keep head of bed raised 45 degrees C. Monitor blood glucose level D. Maintain strict intake and output - D. Maintain strict intake and output 23. A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use? A. Ask the client to describe the pain B. Observe body language and movement C. Identify effective pain relief measures D. Provide a numeric pain scale - A. Ask the client to describe the pain 24. A client presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal discharge. Which action should the nurse take first? A. Start an intravenous infusion B. Administer oxygen via facemask C. Perform a vaginal exam D. Begin continuous fetal monitoring - D. Begin continuous fetal monitoring 25. A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). Which information should the nurse provide? A. Consume a high protein diet B. Increase physical activity C. Take vitamin supplements D. Obtain a prostate-specific antigen blood level test - B. Increase physical activity 26. The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 mL to be infused intravenously over 4 hours. The IV administration set delivers 10gtt/mL. How many gtt/minute should the nurse regulate the infusion? (Round to the nearest whole number) - 42 gtt/min 27. Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care? A. observe color of urine B. Measure body temperature C. Assess skin turgor D. Check for pedal edema - A. Observe color of urine 28. A client fell in the bathroom when left unattended by the unlicensed assistive personnel (UAP). Which information should the nurse include in the client's health record? A. The UAP left the client to assist another client B. The last time client was assisted to the bathroom C. The unit was understaffed when the client fell D. The client fell sustaining a fracture to the left hip - D. The client fell sustaining a fracture to the left hip 29. The nurse is reviewing the diagnostic tests prescribed for a client with a positive skin test. Which subjective findings reported by the client supports the diagnosis of tuberculosis? A. Barking cough and vomiting B. Mucopurulent cough and night sweats C. Dry cough and chest tightness D. Chronic cough and fatty stools - B. Mucopurulent cough and night sweats 30. In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep, and the client become lethargic. Which assessment data should the nurse obtain next? A. Temperature B. Breath sounds C. Blood glucose D. White blood cell count - C. Blood glucose 31. A nurse receives report on a client who is four hours post-total abdominal hysterectomy. The previous nurse reports that it was necessary to change the client's perineal pad hourly and that it is again saturated. The previous nurse also reports that the client's urinary output has decreased. Which action should the nurse implement first? A. Evaluate the skin turgor B. Assess for weakness or dizziness C. Change the perineal pad D. Measure the urinary output - B. Assess for weakness or dizziness 32. The father of a 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care? A. Reassure the client that his child will be allowed to visit B. Provide the client written information about end-of-life care C. Obtain a detailed report from the nurse transferring the client D. Mark the chart with client's request for no heroic measures - C. Obtain a detailed report from the nurse transferring the client 33. While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produces pink blood-tinged sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement? A. Obtain sputum sample B. Document degree of edema C. Initiate hourly urine output measurement D. Administer intravenous diuretics - A. Obtain sputum sample 34. A client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions? (descending order) 1. Observe breathing patterns 2. Assess blood pressure 3. Measure body temperature 4. Palpate for pedal edema 35. A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation? A. Potassium 3.5 mEq/L B. Fingertips feel numb C. Sodium 135 mEq/L D. Cervical spine stiffness - B. Fingertips feel numb 36. An older client is brought to the ED with a sudden onset of confusion that occurred after experiencing a fall at home. The client's daughter, who has power of attorney, has brought the client's prescriptions. Which information should the nurse provide first when reporting to the healthcare provider using SBAR communication? A. currently prescribed medications B. Client's healthcare power of attorney C. Increasing confusion of the client D. Fall at home as reason for admission - C. Increasing confusion of the client 37. The nurse identifies an electrolyte imbalance, a weight gain of 4.4lbs (2kg) in 24 hours and an elevated central venous pressure for a client with full thickness burns. Which intervention should the nurse implement? A. Auscultate for irregular heart rate B. Review arterial blood gases results C. Measure ankle circumference D. Document abdominal girth - A. Auscultate for irregular heart rate 38. The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply) A. Administer a dose of insulin per sliding scale for a client with Type 2 DM B. Start the second blood transfusion for a client 12 hours following a BKA C. Initiate patient controlled analgesia (PCA) pumps for two clients immediately postoperatively D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy E. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty A. Administer a dose of insulin per sliding scale for a client with Type 2 DM D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy E. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty 39. The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity? A. Core strengthening B. Aerobic exercise C. Weight-bearing exercise D. Muscle stretching and toning - B. Aerobic exercise 40. A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse? A. CT scan that was performed 6 months earlier B. Metal hip prosthesis was placed 20 years ago C. Report of client's sobriety for the last 5 years D. Takes metformin for type 2 diabetes mellitus - D. Takes metformin for type 2 diabetes mellitus 41. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (A1C) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale of insulin aspart every 6h are prescribed. What actions should the nurse include in this client's plan of care? (Select all that apply) A. Do not contaminate the insulin aspart so that it is available for IV use B. Review with the client proper foot care and prevention of injury C. Teach subcutaneous injection technique, site rotation, and insulin management D. Coordinate carbohydrate controlled meals at consistent times and intervals. E. Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose F. Fingerstick glucose assessments every 6h with meals – B. Review with client proper foot care and prevention of injury C. Teach subcutaneous injection technique, site rotation, and insulin management D. Coordinate carbohydrate controlled meals at consistent times and intervals F. Fingerstick glucose assessments every 6h with meals 42. The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention? A. A 14yo client with anorexia nervosa who is refusing to eat the evening snack B. A 16yo client diagnosed with major depression who refuses to participate in group C. A 17yo client diagnosed with bipolar disorder who is pacing around the lobby D. An 18yo client with antisocial behavior who is being yelled at by other clients - D. An 18yo client with antisocial behavior who is being yelled at by other clients 43. A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Which action is most important for the nurse to implement? A. Obtain the client's 24-hour dietary recall B. Document mucosal membrane status C. Schedule a consult with a nutritionist D. Initiate prescribed intravenous fluids - D. Initiate prescribed intravenous fluids 44. A pediatric client is taking the beta-adrenergic blocking agent propranolol. In developing a teaching plan, the nurse should teach the parents to report which sign of overdose? A. Bradycardia B. Tachypnea C. Hypertension D. Coughing - A. Bradycardia 45. Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain? A. Upper body muscle strength B. Balance and posture C. Risk for disuse syndrome D. Pressure sore risk - A. Upper body muscle strength 46. A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents? A. A retraining program will need to be initiated when the child returns home. B. Diapering will be provided since hospitalization is stressful to preschoolers C. A potty chair should be brought from home so he can maintain his toileting skills D. Children usually resume their toileting behaviors when they leave the hospital - D. Children usually resume their toileting behaviors when they leave the hospital 47. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) A. Report any client complaint of pain or discomfort B. Evaluate the client for sleep disturbances C. Assess the client for weakness and fatigue D. Weigh the client and report any weight gain E. Note and report the client's food and liquid intake during meals and snacks - A. Report any client complaint of pain or discomfort D. Weigh the client and report any weight gain E. Note and report the client's food and liquid intake during meals and snacks 48. A young adult visits the client reporting symptoms associated with gastritis. Which information in the client's history is most important for the nurse to address in the teaching plan? A. Consumes 10 or more drinks of alcohol every weekend B. Snacks on foods with very high salt content on a daily basis C. Exercises vigorously every evening right before going to bed D. Recently became a vegetarian and eats a lot of high fiber foods - A. Consumes 10 or more drinks of alcohol every weekend 49. After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication? A. Auscultate for bowel sounds in all quadrants B. Ask the client about gastrointestinal pain C. Monitor the client's serum electrolyte levels D. Measure the client's fluid intake and output - B. Ask the client about gastrointestinal pain 50. When assessing a recently delivered, multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding? A. The second stage of labor lasted 10 minutes B. She received butorphanol 2mg IVP during labor C. She is over 35 years of age D. She is a gravida 6, para 5 - D. She is a gravida 6, para 5