Newest 2025 HESI Exit Exam (Next Generation NCLEX
Format) Featuring Accurate And Verified Questions
Designed To Assess Clinical Judgment, Critical
Thinking, And Nursing Competencies Across All
Major Content Areas Including Medical-Surgical,
Pharmacology
A client with type 2 diabetes mellitus is admitted for frequent
hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%.
Insulin glargine 10 units subcutaneously once a day at bedtime and a
sliding scale with insulin aspart q6h are prescribed. What action should
the nurse include in this client's plan of care? <<<correct
answer>>>Fingerstick glucose assessment q6h with meals
Mix bedtime dose of insulin glargine with insulin aspart sliding scale
dose
Review with the client proper foot care and prevention of injury
Do not contaminate the insulin aspart so that it is available for iv use
Coordinate carbohydrate controlled meals at consistent times and
intervals
Teach subcutaneous injection technique, site rotation and insulin
management
,Which problem reported by a client taking lovastatin requires the most
immediate fallow up by the nurse? <<<correct answer>>>Diarrhea and
flatulence
Abdominal cramps
Muscle pain
Altered taste
Rationale: statins can cause rhabdomyolysis, a potentially fatal disease
of skeletal muscle characterized by myoglobinuria and manifested with
muscle pain, so this symptom should immediately be reported to the
HCP.
While assessing a client's chest tube (CT), the nurse discovers bubbling
in the water seal chamber of the chest tube collection device. The
client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120
beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation
88%. Which interventions should the nurse implement? <<<correct
answer>>>Provide supplemental oxygen
Auscultate bilateral lung fields
Administer a nebulizer treatment
Reinforce occlusive CT dressing
Give PRN dose of pain medication
,Rationale: the air bubbles indicate an air leak from the lungs, the chest
tube site, or the chest tube
collection system. Providing oxygen improves the oxygen saturation
until the leak has been resolved.
Auscultating the lung fields helps to identify absent or decrease lung
sound due to collapsing lung.
Before leaving the room of a confused client, the nurse notes that a half
bow knot was used to attach the client's wrist restraints to the movable
portion of the client's bed frame. What action should the nurse take
before leaving the room? <<<correct answer>>>Ensure that the knot can be
quickly released.
Tie the knot with a double turn or square knot.
Move the ties so the restraints are secured to the side rails.
Ensure that the restraints are snug against the client's wrist.
Oral antibiotics are prescribed for an 18-month-old toddler with severe
otitis media. An antipyrine and benzocaine-otic also prescribed for pain
and inflammation. What instruction should the nurse emphasize
concerning the installation of the antipyrine/benzocaine otic solution?
<<<correct answer>>>Place the dropper on the upper outer ear canal and
instill the medication slowly.
Warm the medication in the microwave for 10 seconds before instilling.
Keep the medication refrigerated between administrations.
, Have the child lie with the ear up for one to two minute after
installation.
An older adult male is admitted with complications related to chronic
obstructive pulmonary disease (COPD). He reports progressive dyspnea
that worsens on exertion and his weakness has increased over the past
month. The nurse notes that he has dependent edema in both lower
legs. Based on these assessment findings, which dietary instruction
should the nurse provide? <<<correct answer>>>Limit the intake of high
calorie foods.
Eat meals at the same time daily.
Maintain a low protein diet.
Restrict daily fluid intake.
Rationale: the client is exhibiting signs of cor pulmonale, a complication
of COPD that causes the right
side of the heart to fail. Restricting fluid intake to 1000 to 2000 ml/day,
eating a high-calorie diet at small
frequent meals with foods that are high in protein and low in sodium
can help relive the edema and
decrease workload on the right-side of the heart.
Format) Featuring Accurate And Verified Questions
Designed To Assess Clinical Judgment, Critical
Thinking, And Nursing Competencies Across All
Major Content Areas Including Medical-Surgical,
Pharmacology
A client with type 2 diabetes mellitus is admitted for frequent
hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%.
Insulin glargine 10 units subcutaneously once a day at bedtime and a
sliding scale with insulin aspart q6h are prescribed. What action should
the nurse include in this client's plan of care? <<<correct
answer>>>Fingerstick glucose assessment q6h with meals
Mix bedtime dose of insulin glargine with insulin aspart sliding scale
dose
Review with the client proper foot care and prevention of injury
Do not contaminate the insulin aspart so that it is available for iv use
Coordinate carbohydrate controlled meals at consistent times and
intervals
Teach subcutaneous injection technique, site rotation and insulin
management
,Which problem reported by a client taking lovastatin requires the most
immediate fallow up by the nurse? <<<correct answer>>>Diarrhea and
flatulence
Abdominal cramps
Muscle pain
Altered taste
Rationale: statins can cause rhabdomyolysis, a potentially fatal disease
of skeletal muscle characterized by myoglobinuria and manifested with
muscle pain, so this symptom should immediately be reported to the
HCP.
While assessing a client's chest tube (CT), the nurse discovers bubbling
in the water seal chamber of the chest tube collection device. The
client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120
beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation
88%. Which interventions should the nurse implement? <<<correct
answer>>>Provide supplemental oxygen
Auscultate bilateral lung fields
Administer a nebulizer treatment
Reinforce occlusive CT dressing
Give PRN dose of pain medication
,Rationale: the air bubbles indicate an air leak from the lungs, the chest
tube site, or the chest tube
collection system. Providing oxygen improves the oxygen saturation
until the leak has been resolved.
Auscultating the lung fields helps to identify absent or decrease lung
sound due to collapsing lung.
Before leaving the room of a confused client, the nurse notes that a half
bow knot was used to attach the client's wrist restraints to the movable
portion of the client's bed frame. What action should the nurse take
before leaving the room? <<<correct answer>>>Ensure that the knot can be
quickly released.
Tie the knot with a double turn or square knot.
Move the ties so the restraints are secured to the side rails.
Ensure that the restraints are snug against the client's wrist.
Oral antibiotics are prescribed for an 18-month-old toddler with severe
otitis media. An antipyrine and benzocaine-otic also prescribed for pain
and inflammation. What instruction should the nurse emphasize
concerning the installation of the antipyrine/benzocaine otic solution?
<<<correct answer>>>Place the dropper on the upper outer ear canal and
instill the medication slowly.
Warm the medication in the microwave for 10 seconds before instilling.
Keep the medication refrigerated between administrations.
, Have the child lie with the ear up for one to two minute after
installation.
An older adult male is admitted with complications related to chronic
obstructive pulmonary disease (COPD). He reports progressive dyspnea
that worsens on exertion and his weakness has increased over the past
month. The nurse notes that he has dependent edema in both lower
legs. Based on these assessment findings, which dietary instruction
should the nurse provide? <<<correct answer>>>Limit the intake of high
calorie foods.
Eat meals at the same time daily.
Maintain a low protein diet.
Restrict daily fluid intake.
Rationale: the client is exhibiting signs of cor pulmonale, a complication
of COPD that causes the right
side of the heart to fail. Restricting fluid intake to 1000 to 2000 ml/day,
eating a high-calorie diet at small
frequent meals with foods that are high in protein and low in sodium
can help relive the edema and
decrease workload on the right-side of the heart.
