RN HESI EXIT EXAM VERSION 2 CERTIFICATION
EVALUATION 2026 COMPLETE SOLUTION A+
◉ 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. Answer: D. Maintain strict
intake and output
◉ 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. Answer: A. Ask the client to describe
the pain
,◉ 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. Answer: D. Begin continuous
fetal monitoring
◉ 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. Answer: B.
Increase physical activity
◉ 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). Answer: 42 gtt/min
,◉ 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. Answer: A. Observe color of urine
◉ 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. Answer: D. The
client fell sustaining a fracture to the left hip
◉ 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. Answer: B. Mucopurulent cough
and night sweats
◉ 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. 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. Answer: B. Assess for weakness or
dizziness
EVALUATION 2026 COMPLETE SOLUTION A+
◉ 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. Answer: D. Maintain strict
intake and output
◉ 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. Answer: A. Ask the client to describe
the pain
,◉ 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. Answer: D. Begin continuous
fetal monitoring
◉ 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. Answer: B.
Increase physical activity
◉ 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). Answer: 42 gtt/min
,◉ 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. Answer: A. Observe color of urine
◉ 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. Answer: D. The
client fell sustaining a fracture to the left hip
◉ 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. Answer: B. Mucopurulent cough
and night sweats
◉ 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. 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. Answer: B. Assess for weakness or
dizziness
