HESI RN EXIT EXAM ( 2 VERSIONS) LATEST
UPDATED 2025 WITH COMPLETE SOLUTIONS
A mental health worker is caring for a client with escalating aggressive behavior. Which
action by the MHW warrant immediate intervention by the RN - ANSWER-Is attempting
to physically restrain the patient
A client on the mental health unit is becoming more agitated, shouting at the staff, and
pacing in the hallway. What nursing intervention should the RN Implement first -
ANSWER-Take other clients in the area to the client lounge
A client is admitted to the mental health unit and reports taking extra antianxiety
medication because "I'm so stressed out. I just want to go to sleep" The RN should plan
one on one observation of the client based on which statement - ANSWER-I dont want
to walk nothing matters anymore
A male hospital employee is pushed out of the way by a female employee because of
an oncoming gurney. The pushed employee becomes very angry and swings at the
female employee. Both employees are referred for counseling with the staff psychiatric
RN. Which factor in the pushed employees history is most related to the reaction that
occured - ANSWER-Was physically abused by his mother
The RN documents the mental status of a female client who has been hospitalized for
several days by court order. The client states " I dont need to be here" and tells the RN
that she believes the TV talks to her. The RN should document these assessment
findings in which section of the mental status exam - ANSWER-Insight and Judgment
A client is admitted to the mental health unit reports shortness of breath and dizziness.
The client tells the RN " I feel like I'm going to die". Which nursing
The nurse is giving preop instructions to a 14 yr old scheduled to correct a spinal
curvature. Which statement best demonstrates that learning has taken place? -
ANSWER-I understand I will be in a body cast and I will show you hoy you taught me to
turn
To take the vital signs of a 4 month old child which order will give the most accurate
results? - ANSWER-Respiratory rate, heart rate, rectal temperature
AN otoscope exam of a child's ear reveals a tympanic membrane that is pearly gray,
slightly bulging and not movable. What action should the nurse take next? - ANSWER-
Ask the child if he has has a cold, runny nose or any ear pain lately
,Which restraint should be used for a toddler after a cleft palate repair? - ANSWER-
elbow
What preoperative nursing intervention should be included in the plan of care for an
infant with pyloric stenosis? - ANSWER-Observe for projectile vomiting
A six month old returns from surgery with elbow restraints in place. What nursing
intervention should be included when caring for any restrained child? - ANSWER-
remove restraints one at a time and provide range of motion exercise
A two year old with Down Syndrome is brought to the clinic for his regular physical
exam. The nurse knows which problem is frequently associated with Down Syndrome? -
ANSWER-Congenital Heart Disease
When assessing a child with asthma the nurse should expect intercostal retractions
during - ANSWER-inspiration
When planning the care for a child who has had a cleft lip repair, the nurse knows that
crying should be minimized because it - ANSWER-stresses the suture line
A client with a productive cough has obtained a sputum specimen for culture as
instructed. What action is the best initial nursing action? - ANSWER-Administer the first
dose of prescribed antibiotic therapy
A client is brought to the Emergency Department by ambulance in cardiac arrest with
CPR in progress. The client is intubated and receiving 100% O2 per ambu bag. The
nurse determines the client is cyanotic, cold, and diaphoretic. Which assessment is
most important to obtain? - ANSWER-deep tendon reflexes
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a
client develops pontine myselinolysis. Which intervention should the nurse implement
first? - ANSWER-Reorientate client to his room
A male client with heart failure (HF) calls the clinic and reports he cannot put his shoes
on because they are too tight. Which additional information should the nurse obtain? -
ANSWER-Has his weight changed in the last several days
An older adult with a long hx of COPD is admitted with progressive shortness of breath
and a persistent cough. She is anxious and is complaining of a dry mouth. Which
intervention should the nurse implement? - ANSWER-Apply a high flow venturi mask
A client with a hx of asthma and bronchitis arrives at the clinic with SOB, productive
cough with thickened tenacious mucous and the inability to walk up a flight of stairs
without experiencing breathlessness. Which action is important for the nurse to instruct
the client about self care? - ANSWER-Increase the daily intake of oral fluids to to liquefy
secretions
,A cardiac catherization of a client with heart disease indicates the following blockages
95% LAD 99% proximal circumflex and 95% proximal RCA. The client later asks the
nurse "what does all that mean for me" - ANSWER-3 main arteries have major
blockages with only 1 to 5% of blood flow getting through to the heart muscle
The nurse is caring for a client with a lower left pulmonary abscess which position
should the nurse instruct the client to maintain - ANSWER-left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable
to eat or drink without nausea and vomiting. Which finding should the nurse report to the
healthcare provider - ANSWER-yellow sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a
neuro assessment every 4 hours. which assessment finding warrants immediate
intervention by the nurse? - ANSWER-Increasing Anxiety
Following surgical repair of the bladder a female client is being discharged from the
hospital with an indwelling catheter. Which instruction is most important for the nurse to
provide to the client? - ANSWER-Keep the drainage bag lower than the level of the
bladder
Which client has the highest risk for developing skin cancer - ANSWER-a 65 year old
fair skinned male who is a construction worker
When caring for a client with nephrotic syndrome, which assessment is most important
for the nurse to obtain? - ANSWER-level of consciousness
A female client who was involved in an MVA is admitted with a fractured left femur
which is immobilized using a fracture traction splint in preparation for an open reduction
internal fixation (ORIF) - ANSWER-- verify pedal pulses using a doppler pulse device
-monitor left leg for pain, pallor, paresthesia,paralysis, pressure
-evaluate the application of the splint to the left leg
Lactulose has been prescribed for a client with advanced liver disease. Which finding
should the nurse use to evaluate the effectiveness of this treatment? - ANSWER-a
decrease in lethargy
The nurse is caring for a client with a colostomy. During a teaching session the nurse
recommends that the pouch be emptied - ANSWER-when it is 1/3 to 1/2 full
A client had 20mg of Lasix PO at 10 am. Which would be essential for the nurse to
include at the change of shift report? - ANSWER-The client urine output was 1500 cc in
5 hours
, A client is admitted with a right upper lobe infiltrate and to rule out tuberculosis. The
most appropriate action by the nurse to protect herself would be? - ANSWER-
particulate respirator mask
A client is recovering from a thyroidectomy. While monitoring the clients initial post op
condition which of the following should the nurse report immediately - ANSWER-tetany
and paresthesia
A client diagnosed with Hep C discusses his health history with the admitting nurse. The
nurse should recognize which statement by the client as the most important? -
ANSWER-I had a blood transfusion 15 years ago
A client with a pulmonary embolism has the following ABGs PO2 -70 PCO2-32 PH 7.45
SaO2 87% HCO3 22 based on this data what is the first nursing action - ANSWER-
Administer oxygen
The nurse is caring for a client with sickle cell disease who is scheduled to receive a
unit of packed red blood cells. Which of the following is an appropriate action for the
nurse when administering the infusion - ANSWER-Limit the infusion time of each of the
units to maximum of 4 hours
The nurse is preparing a handout on infant feeding to be distributed to families visiting
the clinic. Which notation should be included in the teaching materials - ANSWER-solid
foods are introduced 1 at a time beginning with cereal
A client is scheduled for an IVP (Intravenous Pyelogram) Which of the following data
from the client hx indicate a potential hazard for this test - ANSWER-allergic to shellfish
When parents call the emergency room to report that a toddler has swallowed drain
cleaner, the nurse instructs them to call for emergency transport to the hospital. While
waiting for an ambulance,
the nurse would suggest for the parents to give sips of which substance? - ANSWER-
Water
Which of the following manifestations observed by the school nurse confirms the
prescence of pediculosis capititis in students - ANSWER-whittish oval specs sticking in
the hair
The nurse is teaching elderly clients how to use multidose inhalers. The nurse is
concerned that the client is unable to coordinate the release of the medication with the
inhalation phase. What is the nurses best recommendation to improve delivery of
medication? - ANSWER-adding a spacer device to the MDI canister
A two year old child is brought to the healthcare providers office with a chief complaint
of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which
statement? - ANSWER-Continue with regular diet and give oral rehydration fluids
UPDATED 2025 WITH COMPLETE SOLUTIONS
A mental health worker is caring for a client with escalating aggressive behavior. Which
action by the MHW warrant immediate intervention by the RN - ANSWER-Is attempting
to physically restrain the patient
A client on the mental health unit is becoming more agitated, shouting at the staff, and
pacing in the hallway. What nursing intervention should the RN Implement first -
ANSWER-Take other clients in the area to the client lounge
A client is admitted to the mental health unit and reports taking extra antianxiety
medication because "I'm so stressed out. I just want to go to sleep" The RN should plan
one on one observation of the client based on which statement - ANSWER-I dont want
to walk nothing matters anymore
A male hospital employee is pushed out of the way by a female employee because of
an oncoming gurney. The pushed employee becomes very angry and swings at the
female employee. Both employees are referred for counseling with the staff psychiatric
RN. Which factor in the pushed employees history is most related to the reaction that
occured - ANSWER-Was physically abused by his mother
The RN documents the mental status of a female client who has been hospitalized for
several days by court order. The client states " I dont need to be here" and tells the RN
that she believes the TV talks to her. The RN should document these assessment
findings in which section of the mental status exam - ANSWER-Insight and Judgment
A client is admitted to the mental health unit reports shortness of breath and dizziness.
The client tells the RN " I feel like I'm going to die". Which nursing
The nurse is giving preop instructions to a 14 yr old scheduled to correct a spinal
curvature. Which statement best demonstrates that learning has taken place? -
ANSWER-I understand I will be in a body cast and I will show you hoy you taught me to
turn
To take the vital signs of a 4 month old child which order will give the most accurate
results? - ANSWER-Respiratory rate, heart rate, rectal temperature
AN otoscope exam of a child's ear reveals a tympanic membrane that is pearly gray,
slightly bulging and not movable. What action should the nurse take next? - ANSWER-
Ask the child if he has has a cold, runny nose or any ear pain lately
,Which restraint should be used for a toddler after a cleft palate repair? - ANSWER-
elbow
What preoperative nursing intervention should be included in the plan of care for an
infant with pyloric stenosis? - ANSWER-Observe for projectile vomiting
A six month old returns from surgery with elbow restraints in place. What nursing
intervention should be included when caring for any restrained child? - ANSWER-
remove restraints one at a time and provide range of motion exercise
A two year old with Down Syndrome is brought to the clinic for his regular physical
exam. The nurse knows which problem is frequently associated with Down Syndrome? -
ANSWER-Congenital Heart Disease
When assessing a child with asthma the nurse should expect intercostal retractions
during - ANSWER-inspiration
When planning the care for a child who has had a cleft lip repair, the nurse knows that
crying should be minimized because it - ANSWER-stresses the suture line
A client with a productive cough has obtained a sputum specimen for culture as
instructed. What action is the best initial nursing action? - ANSWER-Administer the first
dose of prescribed antibiotic therapy
A client is brought to the Emergency Department by ambulance in cardiac arrest with
CPR in progress. The client is intubated and receiving 100% O2 per ambu bag. The
nurse determines the client is cyanotic, cold, and diaphoretic. Which assessment is
most important to obtain? - ANSWER-deep tendon reflexes
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a
client develops pontine myselinolysis. Which intervention should the nurse implement
first? - ANSWER-Reorientate client to his room
A male client with heart failure (HF) calls the clinic and reports he cannot put his shoes
on because they are too tight. Which additional information should the nurse obtain? -
ANSWER-Has his weight changed in the last several days
An older adult with a long hx of COPD is admitted with progressive shortness of breath
and a persistent cough. She is anxious and is complaining of a dry mouth. Which
intervention should the nurse implement? - ANSWER-Apply a high flow venturi mask
A client with a hx of asthma and bronchitis arrives at the clinic with SOB, productive
cough with thickened tenacious mucous and the inability to walk up a flight of stairs
without experiencing breathlessness. Which action is important for the nurse to instruct
the client about self care? - ANSWER-Increase the daily intake of oral fluids to to liquefy
secretions
,A cardiac catherization of a client with heart disease indicates the following blockages
95% LAD 99% proximal circumflex and 95% proximal RCA. The client later asks the
nurse "what does all that mean for me" - ANSWER-3 main arteries have major
blockages with only 1 to 5% of blood flow getting through to the heart muscle
The nurse is caring for a client with a lower left pulmonary abscess which position
should the nurse instruct the client to maintain - ANSWER-left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable
to eat or drink without nausea and vomiting. Which finding should the nurse report to the
healthcare provider - ANSWER-yellow sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a
neuro assessment every 4 hours. which assessment finding warrants immediate
intervention by the nurse? - ANSWER-Increasing Anxiety
Following surgical repair of the bladder a female client is being discharged from the
hospital with an indwelling catheter. Which instruction is most important for the nurse to
provide to the client? - ANSWER-Keep the drainage bag lower than the level of the
bladder
Which client has the highest risk for developing skin cancer - ANSWER-a 65 year old
fair skinned male who is a construction worker
When caring for a client with nephrotic syndrome, which assessment is most important
for the nurse to obtain? - ANSWER-level of consciousness
A female client who was involved in an MVA is admitted with a fractured left femur
which is immobilized using a fracture traction splint in preparation for an open reduction
internal fixation (ORIF) - ANSWER-- verify pedal pulses using a doppler pulse device
-monitor left leg for pain, pallor, paresthesia,paralysis, pressure
-evaluate the application of the splint to the left leg
Lactulose has been prescribed for a client with advanced liver disease. Which finding
should the nurse use to evaluate the effectiveness of this treatment? - ANSWER-a
decrease in lethargy
The nurse is caring for a client with a colostomy. During a teaching session the nurse
recommends that the pouch be emptied - ANSWER-when it is 1/3 to 1/2 full
A client had 20mg of Lasix PO at 10 am. Which would be essential for the nurse to
include at the change of shift report? - ANSWER-The client urine output was 1500 cc in
5 hours
, A client is admitted with a right upper lobe infiltrate and to rule out tuberculosis. The
most appropriate action by the nurse to protect herself would be? - ANSWER-
particulate respirator mask
A client is recovering from a thyroidectomy. While monitoring the clients initial post op
condition which of the following should the nurse report immediately - ANSWER-tetany
and paresthesia
A client diagnosed with Hep C discusses his health history with the admitting nurse. The
nurse should recognize which statement by the client as the most important? -
ANSWER-I had a blood transfusion 15 years ago
A client with a pulmonary embolism has the following ABGs PO2 -70 PCO2-32 PH 7.45
SaO2 87% HCO3 22 based on this data what is the first nursing action - ANSWER-
Administer oxygen
The nurse is caring for a client with sickle cell disease who is scheduled to receive a
unit of packed red blood cells. Which of the following is an appropriate action for the
nurse when administering the infusion - ANSWER-Limit the infusion time of each of the
units to maximum of 4 hours
The nurse is preparing a handout on infant feeding to be distributed to families visiting
the clinic. Which notation should be included in the teaching materials - ANSWER-solid
foods are introduced 1 at a time beginning with cereal
A client is scheduled for an IVP (Intravenous Pyelogram) Which of the following data
from the client hx indicate a potential hazard for this test - ANSWER-allergic to shellfish
When parents call the emergency room to report that a toddler has swallowed drain
cleaner, the nurse instructs them to call for emergency transport to the hospital. While
waiting for an ambulance,
the nurse would suggest for the parents to give sips of which substance? - ANSWER-
Water
Which of the following manifestations observed by the school nurse confirms the
prescence of pediculosis capititis in students - ANSWER-whittish oval specs sticking in
the hair
The nurse is teaching elderly clients how to use multidose inhalers. The nurse is
concerned that the client is unable to coordinate the release of the medication with the
inhalation phase. What is the nurses best recommendation to improve delivery of
medication? - ANSWER-adding a spacer device to the MDI canister
A two year old child is brought to the healthcare providers office with a chief complaint
of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which
statement? - ANSWER-Continue with regular diet and give oral rehydration fluids
