1|Page
HESI RN EXIT EXAM V1| COMPREHENSIVE
Q&A FOR CERTIFICATION SUCCESS
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 - correct-answer -C. Blood glucose
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 - correct-answer -B. Assess for weakness or
dizziness
,2|Page
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 - correct-answer -C.
Obtain a detailed report from the nurse transferring the client
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 - correct-answer -A. Obtain sputum sample
,3|Page
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) - correct-answer -1. Observe breathing patterns
2. Assess blood pressure
3. Measure body temperature
4. Palpate for pedal edema
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 - correct-answer -B. Fingertips feel numb
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
, 4|Page
D. Fall at home as reason for admission - correct-answer -C. Increasing confusion
of the client
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 - correct-answer -A. Auscultate for irregular heart
rate
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 - correct-answer -A. Administer a dose of insulin per sliding scale for
a client with Type 2 DM
HESI RN EXIT EXAM V1| COMPREHENSIVE
Q&A FOR CERTIFICATION SUCCESS
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 - correct-answer -C. Blood glucose
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 - correct-answer -B. Assess for weakness or
dizziness
,2|Page
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 - correct-answer -C.
Obtain a detailed report from the nurse transferring the client
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 - correct-answer -A. Obtain sputum sample
,3|Page
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) - correct-answer -1. Observe breathing patterns
2. Assess blood pressure
3. Measure body temperature
4. Palpate for pedal edema
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 - correct-answer -B. Fingertips feel numb
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
, 4|Page
D. Fall at home as reason for admission - correct-answer -C. Increasing confusion
of the client
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 - correct-answer -A. Auscultate for irregular heart
rate
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 - correct-answer -A. Administer a dose of insulin per sliding scale for
a client with Type 2 DM
