HESI EXIT EXAM REVIEW
(NIGHTINGALE COLLEGE) - LATEST
2027 ACTUAL QUESTIONS AND
CORRECT DETAILED ANSWERS
1. A client with a spinal cord injury at the T4 level reports a sudden, severe headache and
nasal congestion. The nurse notes a blood pressure of 180/100 mmHg and bradycardia. What
is the priority nursing action?
A. Administer an antihypertensive medication.
B. Place the client in a flat supine position.
C. Check the client’s bladder for distension.
D. Perform a neurological assessment.
Answer: C
Conceptual Explanation: The symptoms indicate autonomic dysreflexia, a medical
emergency. The first priority is to identify and remove the stimulus, commonly a distended
bladder or impacted bowel, while sitting the patient up to lower BP.
2. A patient is prescribed Phenelzine, a Monoamine Oxidase Inhibitor (MAOI). Which food
choice by the patient indicates a need for further teaching?
A. Fresh grilled salmon
,B. Steamed broccoli
C. Aged cheddar cheese
D. Sliced apples
Answer: C
Conceptual Explanation: Foods high in tyramine, such as aged cheeses, cured meats, and
fermented products, must be avoided while taking MAOIs to prevent a hypertensive crisis.
3. The nurse is monitoring a client receiving Digoxin. Which of the following laboratory results
should the nurse report immediately?
A. Serum Potassium 3.2 mEq/L
B. Serum Digoxin 1.2 ng/mL
C. Serum Sodium 140 mEq/L
D. Serum Magnesium 2.0 mEq/L
Answer: A
Conceptual Explanation: Hypokalemia (potassium below 3.5 mEq/L) increases the risk of
digoxin toxicity. Even if the digoxin level is therapeutic, low potassium can trigger life-
threatening arrhythmias.
4. A client diagnosed with Bipolar Disorder is taking Lithium Carbonate. The nurse notes a
serum lithium level of 1.8 mEq/L. Which action is most appropriate?
A. Hold the dose and notify the healthcare provider.
, B. Increase fluid intake for the next 24 hours.
C. Administer the next scheduled dose.
D. Document this as a therapeutic finding.
Answer: A
Conceptual Explanation: The therapeutic range for lithium is 0.6 to 1.2 mEq/L. A level of
1.8 mEq/L indicates toxicity and requires immediate intervention, usually holding the drug
and notifying the provider.
5. A client in labor is receiving Magnesium Sulfate for preeclampsia. Which finding should the
nurse identify as a sign of magnesium toxicity?
A. Hyperactive deep tendon reflexes
B. Increased urinary output
C. Blood pressure of 150/95 mmHg
D. Respiratory rate of 10 breaths per minute
Answer: D
Conceptual Explanation: Signs of magnesium toxicity include respiratory depression (RR
< 12), loss of deep tendon reflexes, and decreased urinary output. Calcium gluconate is the
antidote.
(NIGHTINGALE COLLEGE) - LATEST
2027 ACTUAL QUESTIONS AND
CORRECT DETAILED ANSWERS
1. A client with a spinal cord injury at the T4 level reports a sudden, severe headache and
nasal congestion. The nurse notes a blood pressure of 180/100 mmHg and bradycardia. What
is the priority nursing action?
A. Administer an antihypertensive medication.
B. Place the client in a flat supine position.
C. Check the client’s bladder for distension.
D. Perform a neurological assessment.
Answer: C
Conceptual Explanation: The symptoms indicate autonomic dysreflexia, a medical
emergency. The first priority is to identify and remove the stimulus, commonly a distended
bladder or impacted bowel, while sitting the patient up to lower BP.
2. A patient is prescribed Phenelzine, a Monoamine Oxidase Inhibitor (MAOI). Which food
choice by the patient indicates a need for further teaching?
A. Fresh grilled salmon
,B. Steamed broccoli
C. Aged cheddar cheese
D. Sliced apples
Answer: C
Conceptual Explanation: Foods high in tyramine, such as aged cheeses, cured meats, and
fermented products, must be avoided while taking MAOIs to prevent a hypertensive crisis.
3. The nurse is monitoring a client receiving Digoxin. Which of the following laboratory results
should the nurse report immediately?
A. Serum Potassium 3.2 mEq/L
B. Serum Digoxin 1.2 ng/mL
C. Serum Sodium 140 mEq/L
D. Serum Magnesium 2.0 mEq/L
Answer: A
Conceptual Explanation: Hypokalemia (potassium below 3.5 mEq/L) increases the risk of
digoxin toxicity. Even if the digoxin level is therapeutic, low potassium can trigger life-
threatening arrhythmias.
4. A client diagnosed with Bipolar Disorder is taking Lithium Carbonate. The nurse notes a
serum lithium level of 1.8 mEq/L. Which action is most appropriate?
A. Hold the dose and notify the healthcare provider.
, B. Increase fluid intake for the next 24 hours.
C. Administer the next scheduled dose.
D. Document this as a therapeutic finding.
Answer: A
Conceptual Explanation: The therapeutic range for lithium is 0.6 to 1.2 mEq/L. A level of
1.8 mEq/L indicates toxicity and requires immediate intervention, usually holding the drug
and notifying the provider.
5. A client in labor is receiving Magnesium Sulfate for preeclampsia. Which finding should the
nurse identify as a sign of magnesium toxicity?
A. Hyperactive deep tendon reflexes
B. Increased urinary output
C. Blood pressure of 150/95 mmHg
D. Respiratory rate of 10 breaths per minute
Answer: D
Conceptual Explanation: Signs of magnesium toxicity include respiratory depression (RR
< 12), loss of deep tendon reflexes, and decreased urinary output. Calcium gluconate is the
antidote.
