HESI EXIT 2026/2027 V4 160
Questions with Answers 160
Questions with Answers Top mark
guaranteed
Course
HESI EXIT 2026/2027 V4
1. A nurse is assessing a client with acute left-sided heart failure. Which finding requires
immediate intervention?
A. Bilateral ankle edema
B. Jugular venous distention
C. Pink, frothy sputum
D. Weight gain of 2 lb (0.9 kg)
Answer: C. Pink, frothy sputum
Rationale: Pink frothy sputum indicates acute pulmonary edema, a life-threatening emergency
requiring immediate intervention.
2. A client receiving IV potassium reports burning at the infusion site. What is the nurse's
priority action?
A. Slow the infusion and assess the IV site.
B. Increase the infusion rate.
C. Stop the infusion permanently.
D. Apply a warm compress without assessment.
Answer: A. Slow the infusion and assess the IV site.
Rationale: Potassium is irritating to veins. The nurse should assess IV patency and reduce the
infusion rate as appropriate.
3. Which laboratory value requires immediate provider notification?
A. Sodium 138 mEq/L
,B. Potassium 6.2 mEq/L
C. Calcium 9.2 mg/dL
D. Magnesium 2.0 mg/dL
Answer: B. Potassium 6.2 mEq/L
Rationale: Severe hyperkalemia places the client at risk for life-threatening cardiac
dysrhythmias.
4. A client with COPD is receiving oxygen. Which assessment finding indicates effective
therapy?
A. Respiratory rate 10/min
B. Oxygen saturation 90–92%
C. PaCO₂ 60 mmHg
D. Increased accessory muscle use
Answer: B. Oxygen saturation 90–92%
Rationale: For many stable COPD patients, an SpO₂ target of 88–92% is appropriate to maintain
oxygenation while reducing the risk of oxygen-induced hypercapnia.
5. Which client should the nurse assess first?
A. Stable postoperative client requesting pain medication
B. Client with chest pain and diaphoresis
C. Client awaiting discharge instructions
D. Client requesting a blanket
Answer: B. Client with chest pain and diaphoresis
Rationale: Possible acute coronary syndrome requires immediate assessment.
6. Which finding is expected in diabetic ketoacidosis (DKA)?
A. Bradycardia
,B. Kussmaul respirations
C. Hypoglycemia
D. Hypertension
Answer: B. Kussmaul respirations
Rationale: Deep, rapid respirations help compensate for metabolic acidosis.
7. Which medication should the nurse question?
A. Insulin for blood glucose 310 mg/dL
B. Digoxin for apical pulse of 48 beats/min
C. Acetaminophen for fever
D. Furosemide for pulmonary edema
Answer: B. Digoxin for apical pulse of 48 beats/min
Rationale: Digoxin should generally be withheld and the provider notified if the apical pulse is
below 60 beats/min in an adult.
8. Which assessment finding is most consistent with hypoglycemia?
A. Warm, dry skin
B. Diaphoresis and confusion
C. Polyuria
D. Fruity breath odor
Answer: B. Diaphoresis and confusion
9. A client suddenly becomes short of breath after surgery. Which complication should the
nurse suspect first?
A. Pulmonary embolism
B. Pneumonia
C. Atelectasis
, D. Pleural effusion
Answer: A. Pulmonary embolism
10. Which electrolyte imbalance is most likely to cause peaked T waves?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypocalcemia
Answer: B. Hyperkalemia
11. Which intervention best prevents catheter-associated urinary tract infections?
A. Routine irrigation
B. Maintain a closed drainage system
C. Empty the drainage bag once daily
D. Disconnect tubing for specimen collection
Answer: B. Maintain a closed drainage system
12. A client receiving warfarin has an INR of 5.5. What is the priority nursing action?
A. Administer the scheduled dose.
B. Hold the medication and notify the provider.
C. Encourage foods high in vitamin K immediately.
D. Increase fluid intake.
Answer: B. Hold the medication and notify the provider.
13. Which client is at highest risk for pressure injury?
A. Ambulatory client with hypertension
Questions with Answers 160
Questions with Answers Top mark
guaranteed
Course
HESI EXIT 2026/2027 V4
1. A nurse is assessing a client with acute left-sided heart failure. Which finding requires
immediate intervention?
A. Bilateral ankle edema
B. Jugular venous distention
C. Pink, frothy sputum
D. Weight gain of 2 lb (0.9 kg)
Answer: C. Pink, frothy sputum
Rationale: Pink frothy sputum indicates acute pulmonary edema, a life-threatening emergency
requiring immediate intervention.
2. A client receiving IV potassium reports burning at the infusion site. What is the nurse's
priority action?
A. Slow the infusion and assess the IV site.
B. Increase the infusion rate.
C. Stop the infusion permanently.
D. Apply a warm compress without assessment.
Answer: A. Slow the infusion and assess the IV site.
Rationale: Potassium is irritating to veins. The nurse should assess IV patency and reduce the
infusion rate as appropriate.
3. Which laboratory value requires immediate provider notification?
A. Sodium 138 mEq/L
,B. Potassium 6.2 mEq/L
C. Calcium 9.2 mg/dL
D. Magnesium 2.0 mg/dL
Answer: B. Potassium 6.2 mEq/L
Rationale: Severe hyperkalemia places the client at risk for life-threatening cardiac
dysrhythmias.
4. A client with COPD is receiving oxygen. Which assessment finding indicates effective
therapy?
A. Respiratory rate 10/min
B. Oxygen saturation 90–92%
C. PaCO₂ 60 mmHg
D. Increased accessory muscle use
Answer: B. Oxygen saturation 90–92%
Rationale: For many stable COPD patients, an SpO₂ target of 88–92% is appropriate to maintain
oxygenation while reducing the risk of oxygen-induced hypercapnia.
5. Which client should the nurse assess first?
A. Stable postoperative client requesting pain medication
B. Client with chest pain and diaphoresis
C. Client awaiting discharge instructions
D. Client requesting a blanket
Answer: B. Client with chest pain and diaphoresis
Rationale: Possible acute coronary syndrome requires immediate assessment.
6. Which finding is expected in diabetic ketoacidosis (DKA)?
A. Bradycardia
,B. Kussmaul respirations
C. Hypoglycemia
D. Hypertension
Answer: B. Kussmaul respirations
Rationale: Deep, rapid respirations help compensate for metabolic acidosis.
7. Which medication should the nurse question?
A. Insulin for blood glucose 310 mg/dL
B. Digoxin for apical pulse of 48 beats/min
C. Acetaminophen for fever
D. Furosemide for pulmonary edema
Answer: B. Digoxin for apical pulse of 48 beats/min
Rationale: Digoxin should generally be withheld and the provider notified if the apical pulse is
below 60 beats/min in an adult.
8. Which assessment finding is most consistent with hypoglycemia?
A. Warm, dry skin
B. Diaphoresis and confusion
C. Polyuria
D. Fruity breath odor
Answer: B. Diaphoresis and confusion
9. A client suddenly becomes short of breath after surgery. Which complication should the
nurse suspect first?
A. Pulmonary embolism
B. Pneumonia
C. Atelectasis
, D. Pleural effusion
Answer: A. Pulmonary embolism
10. Which electrolyte imbalance is most likely to cause peaked T waves?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypocalcemia
Answer: B. Hyperkalemia
11. Which intervention best prevents catheter-associated urinary tract infections?
A. Routine irrigation
B. Maintain a closed drainage system
C. Empty the drainage bag once daily
D. Disconnect tubing for specimen collection
Answer: B. Maintain a closed drainage system
12. A client receiving warfarin has an INR of 5.5. What is the priority nursing action?
A. Administer the scheduled dose.
B. Hold the medication and notify the provider.
C. Encourage foods high in vitamin K immediately.
D. Increase fluid intake.
Answer: B. Hold the medication and notify the provider.
13. Which client is at highest risk for pressure injury?
A. Ambulatory client with hypertension
