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HESI Comprehensive Exit Exam 2025 – Ultimate
150 - Question Practice Bank, Expert Answer
Rationales, Complete Study Guide, and NCLEX
Success Blueprint for Nursing Students
A client with diabetes mellitus calls the clinic nurse and reports that he/she has been vomiting during the night and now has diarrhea. Which question does the nurse make a priority of asking the client? "Do you have a fever?" "Did you eat any breakfast?" "Are you urinating frequently?" "Have you tested your blood glucose?" - - correct ans- - "Have you tested your blood glucose?" Rationale: The priority is learning whether the client has tested his/her blood glucose level and what the level is. During illness, the client should follow the "sick-day rules" for diabetics. The blood glucose level should be checked every 4 hours. Urine is tested for ketones if the blood glucose level is greater than 240 mg/dL (13.3 mmol/L). The client should take the prescribed insulin or oral antidiabetic medication and should drink 8 to 12 oz (135 to 350 mL) of sugar-free liquids every hour when awake. The client should notify the primary health care provider if he/she becomes ill. The remaining options are questions that may be asked, but they are not the priority. A nurse is providing information about the storage of insulin to a client who will be self- administering regular insulin. What does the nurse tell the client? That placing the vial near heat or in sunlight will not affect the insulin To freeze unopened vials and remove a vial from the freezer 24 hours before opening it That insulin stored at room temperature causes more discomfort on injection than does cold insulin
That the vial in current use may be kept at room temperature for as long as 1 month without significant loss of activity - - correct ans- - That the vial in current use may be kept at room temperature for as long as 1 month without significant loss of activity Rationale: Insulin preparations are stable at room temperature for as long as 1 month without significant loss of chemical activity. Direct sunlight and extreme heat must be avoided. Insulin should not be frozen. If the insulin is frozen, the insulin should be discarded and the nurse should obtain another vial. Insulin stored at room temperature causes less discomfort on injection than does cold insulin. A nurse reviews the medical record of a client with histoplasmosis. Which clinical manifestation of this infection does the nurse expect to see documented? Neurological deficits Cardiac dysrhythmias Gastrointestinal disturbances Flulike pulmonary signs/symptoms - - correct ans- - Flulike pulmonary signs/symptoms Rationale: Histoplasmosis is a fungal infection of the lungs. The client typically experiences a flulike pulmonary illness with cough, chest pain, dyspnea, headache, fever, arthralgia, anorexia, erythema nodosum, hepatomegaly, and splenomegaly. Neurological disturbances, gastrointestinal disturbances, and cardiac dysrhythmias are not associated with this infection. A client with a medical history of diabetes mellitus is found to have sarcoidosis and oral prednisone is prescribed. The nurse provides instructions to the client about the medication. What does the nurse tell the client? Eat foods that are high in sodium Decrease the daily dose of insulin Eat foods that are low in potassium
Complaints of mild chest discomfort Increased breath sounds on auscultation Deep respirations, 18 breaths/min - - correct ans- - Asymmetrical chest movement Rationale: The nurse specifically notes paradoxical breathing (asymmetrical chest movement); oscillation of the mediastinum; increasing dyspnea; rapid, shallow respirations; accessory muscle breathing; restlessness; decreased breath sounds on auscultation; cyanosis; and anxiety related to difficulty breathing. The client will also complain of severe chest pain. Flail chest is a thoracic injury resulting in paradoxical motion of the chest-wall segment. This causes the mediastinal structures to swing back and forth with respiration. A client is found to have hypoxemic respiratory failure. Which finding does the nurse expect to note on review of the results of the client's arterial blood gas (ABG) analysis? Pao2 of 73 mm Hg, Paco2 of 62 mm Hg Pao2 of 58 mm Hg, Paco2 of 35 mm Hg Pao2 of 60 mm Hg, Paco2 of 45 mm Hg Pao2 of 49 mm Hg, Paco2 of 32 mm Hg - - correct ans- - Pao2 of 49 mm Hg, Paco2 of 32 mm Hg Rationale: Hypoxemic respiratory failure is characterized by a low Pao2 (less than 55 mm Hg) and a normal or low Paco2. The normal Pao2 is 80 to 100 mm Hg and the normal Paco2 is 35 to 45 mm Hg. Respiratory failure may be classified, according to the underlying pathophysiology, as hypoxemic respiratory failure or hypoxemic-hypercapnic respiratory failure. Hypoxemic-hypercapnic respiratory failure is characterized by a low Pao2 (less than 55 mm Hg) and an increased Paco2 (greater than 50 mm Hg). A Pao2 of 49 mm Hg and Paco2 of 32 mm Hg is the only option that characterizes hypoxemic respiratory failure. A client with acute gouty arthritis is being started on medication therapy with indomethacin. The nurse provides medication instructions to the client. How does the nurse tell the client to take the medication?
At bedtime With food 1 hour before meals On an empty stomach - - correct ans- - With food Rationale: The client is instructed to take the medication with food. Indomethacin is a nonsteroidal antiinflammatory medication that produces analgesic and antiinflammatory effects by inhibiting prostaglandin synthesis. Adverse effects include ulceration of the esophagus, stomach, duodenum, and small intestine. An emergency department (ED) nurse is monitoring a client who sustained a severe inhalation burn injury during a fire in which the client was trapped in an enclosed space. The nurse auscultates the client's trachea and notes that the previously heard wheezing sounds have disappeared. What is the most appropriate action the nurse should take? Continue monitoring the client Notify the emergency department (ED) primary health care provider Document the client's improvement in the medical record Remove the oxygen mask and fit the client with a nasal - - correct ans- - Notify the emergency department (ED) primary health care provider Rationale: The most appropriate action by the nurse would be to notify the ED primary health care provider immediately. A client with a severe inhalation injury may sustain such progressive obstruction that within a short time he/she cannot force air through the narrowed airways. As a result, the wheezing sounds disappear. This finding indicates impending airway obstruction and demands immediate intubation. A client with an inhalation burn injury is at risk for respiratory complications. Upper-airway edema and inhalation injury are most notable in the trachea and main stem bronchi. Auscultation of these areas reveals wheezes, which are a sign/symptom of obstruction. Continuing to monitor the client, documenting the client's improvement in the medical record, and removing the oxygen mask and fitting the client with a nasal cannula are all incorrect and would delay necessary interventions.
A postoperative client with deep-vein thrombosis is at risk for pulmonary embolism. For which characteristic sign/symptom of this complication does the nurse monitor the client? Pleuritic chest pain Slowed heart rate Chills and a high fever Decreased respiratory rate - - correct ans- - Pleuritic chest pain Rationale: The characteristic signs/symptoms of pulmonary embolism are dyspnea, tachypnea, tachycardia, and pleuritic chest pain (sharp, stabbing pain on inspiration). Pulmonary embolism, whch results in blockage of the main artery of the lung or one of its branches, occurs when an object, such as a clot, or substance travels from elsewhere in the body through the bloodstream (embolism). The client may become apprehensive and restless. A low-grade fever may occur. Chills and a high fever are characteristics of an infection. A nurse caring for a client 24 hours after a radical neck dissection notes the presence of serosanguineous drainage in the portable wound suction device attached to the surgical site. On the basis of this finding, what should the nurse do? Document the findings Contact the primary health care provider Ask the primary health care provider to remove the drains Increase the pressure on the wound suction device - - correct ans- - Document the findings Rationale: Because the findings detailed in the question are expected, the nurse would document them. Immediately after radical neck dissection, the client will have a wound drain in the neck, attached to portable suction. The nurse places the client in the semi- Fowler position to minimize postoperative edema and monitors the neck drainage for
volume and color. Sanguineous and serosanguineous drainage is expected in the 72 hours after surgery. Once drainage has stopped, the wound drains are removed. Although previously well controlled with glyburide, a client's fasting blood glucose has been running 180 to 200 mg/dL (10 to 11.1 mmol/L). On reviewing the client's record, which medication, recently added to the client's regimen, does the nurse recognize as a possible contributor to the hyperglycemia? Atenolol Phenelzine Allopurinol Lithium carbonate - - correct ans- - Lithium carbonate Rationale: Glyburide is a hypoglycemic medication. If the client takes a corticosteroid, thiazide diuretic, or lithium carbonate concurrently, the effect of the glyburide is diminished. Lithium carbonate, an antimanic medication, may increase the blood glucose level. Phenelzine is a monoamine oxidase inhibitor. Atenolol is a beta-blocker. Allopurinol is a xanthine oxidase inhibitor. These medications may amplify the effects of an oral hypoglycemic. A nurse is performing an assessment of a client with suspected pheochromocytoma. Which clinical manifestation does the nurse expect to note? Weight gain Flushed face Client complaint of diarrhea A blood pressure higher than the normal range - - correct ans- - A blood pressure higher than the normal range Rationale: Pheochromocytoma is a catecholamine-producing tumor arising from cells of the adrenal medulla and sympathetic ganglia. These tumors release excessive amounts of catecholamines, mainly norepinephrine, with associated signs/symptoms
The newborn must be isolated from the mother. All neonates born to HIV-positive clients will acquire infection. Administer zidovudine to the newborn as prescribed for the first 6 weeks. For all neonates born to HIV-positive clients, an HIV culture is recommended at 1 and 4 months after birth. All HIV-exposed newborns should be treated with medication to prevent infection by Pneumocystis jiroveci. Neonates born to HIV-positive clients never test positive at birth because antibodies received from the mother may persist for 18 months after birth. - - correct ans- - Administer zidovudine to the newborn as prescribed for the first 6 weeks. For all neonates born to HIV-positive clients, an HIV culture is recommended at 1 and 4 months after birth. All HIV-exposed newborns should be treated with medication to prevent infection by Pneumocystis jiroveci. Rationale: The nurse should administer zidovudine to the newborn as prescribed for the first 6 weeks of life. Also, for all neonates born to HIV-positive clients, an HIV culture is recommended at 1 and 4 months after birth. In addition, all HIV-exposed newborns should be treated with medication to prevent infection by Pneumocystis jiroveci. The newborn can room with the mother. All neonates acquire maternal antibody to HIV infection, but not all acquire infection. Neonates born to HIV-positive clients may test positive because antibodies received from the mother may persist for 18 months after birth. A client is found to have iron-deficiency anemia, and ferrous sulfate is prescribed. What does the nurse tell the client is best to take the medication with? Milk Apple juice Orange juice Scrambled eggs - - correct ans- - Orange juice
Rationale: Ferrous sulfate is an iron preparation, and the client is instructed to take the medication with orange juice or another vitamin C-containing product to increase absorption of the iron. Milk and eggs inhibit the absorption of iron. Orange juice is higher in vitamin C than apple juice. A nurse is monitoring a client with pheochromocytoma who is receiving an intravenous (IV) infusion of phentolamine. Which vital sign does the nurse monitor most closely during the infusion? Apical pulse Respirations Temperature Blood pressure - - correct ans- - Blood pressure Rationale: The nurse most closely checks the client's blood pressure every 15 minutes during infusion of the medication. Pheochromocytoma is a catecholamine-producing tumor arising from cells of the adrenal medulla and sympathetic ganglia. These tumors release excessive amounts of catecholamines, mainly norepinephrine. Most affected clients present with hypertensive crises that may be treated with phentolamine. This medication, a short-acting alpha-adrenergic blocker is given by way of IV bolus or infusion for a hypertensive crisis. Prednisone 5 mg/day has been prescribed for a client with a chronic respiratory disorder, and the nurse provides instructions to the client about the medication. What does the nurse tell the client to do? Take the medication on an empty stomach Take half of the daily dose if weight gain occurs Stop taking the medication if the ankles begin to swell Call the primary health care provider if a fever, sore throat, or muscle aches develop - - correct ans- - Call the primary health care provider if a fever, sore throat, or muscle aches develop
Mucous membranes - - correct ans- - Mucous membranes Rationale: Assessment of the skin, sclera, and mucous membranes provides the best data regarding the presence of jaundice. The color of the lips provides data regarding the presence of cyanosis. Although assessment of the skin provides adequate data regarding jaundice, the soles and palms are not the best areas of skin for assessment. Jaundice needs to be distinguished from yellow or green skin color resulting from carotenemia or quinacrine (drug used for treatment of giardiasis), The resultant yellow skin color is differentiated from jaundice by the absence of yellow color in mucous membranes and sclerae, the normal urine color, and the accentuation of yellow-brown carotenoid pigment in the palms, soles, and nasolabial folds. A mother calls the emergency department and tells the nurse that her 3-year-old child drank ammonia from a bottle while the mother was cleaning house. What does the nurse tell the mother to immediately do? Induce vomiting Call the child's primary health care provider Bring the child to the emergency department Encourage the child to drink water or milk in small amounts - - correct ans- - Encourage the child to drink water or milk in small amounts Rationale: The nurse tells the mother to immediately administer water or milk to dilute the toxic effects of acid or alkali ingestion. These substances, when ingested, may cause burning of tissue along the gastrointestinal tract. Because these caustic substances continue to cause damage until they are neutralized, induction of emesis is contraindicated. Although calling the child's primary health care provider and bringing the child to the emergency department may each be necessary, they are not the actions to be taken immediately, because they would delay necessary treatment. Calcium disodium edetate and dimercaprol is prescribed for a child with lead poisoning. What does the nurse ask the child's mother before administering the medications?
"Can your child swallow pills?" "Has your child been running a fever?" "Does your child have an allergy to peanuts?" "How long has your child been exposed to the lead?" - - correct ans- - "Does your child have an allergy to peanuts?" Rationale: Dimercaprol must not be used in the presence of a glucose- 6 - phosphate dehydrogenase deficiency (G6PD) or peanut allergy, nor should it be given in conjunction with iron. Therefore, the nurse must ask about allergy to peanuts. Dimercaprol may be used in conjunction with EDTA to treat lead poisoning. Dimercaprol is administered by way of deep intramuscular injection. Calcium disodium edetate is administered by way of the intravenous or intramuscular route. The assessment questions noted in the remaining options are unrelated to the administration of this medication. A child is brought to the emergency department by ambulance after swallowing several capsules of acetaminophen. What statement by the nurse indicates a need for further information? "We need to administer the antidote N-acetyl cysteine and dilute it in juice or soda." "A loading dose of N-acetyl cysteine has to be followed by maintenance doses." Incorrect "We need to give N-acetyl cysteine before we do gastric lavage with activated charcoal." "If the child is unconscious, we must do gastric lavage with activated charcoal to decrease the absorption of acetaminophen." - - correct ans- - "We need to give N-acetyl cysteine before we do gastric lavage with activated charcoal." Rationale: There is a need for further information if the nurse states, "We need to give N- acetyl cysteine before we do gastric lavage with activated charcoal." Activated charcoal with lavage is done if the child is unconscious, but N-acetyl cysteine cannot be used because activated charcoal inactivates the antidote. If given orally, it can be diluted in juice or soda, and a loading dose of N-acetyl cysteine must be followed by maintenance doses.
Administer IV fluids to prevent hypovolemic shock - - correct ans- - Maintain a patent airway Preserve vital organ functioning Administer IV fluids to prevent hypovolemic shock Rationale: The primary goals for the client with a burn injury are to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning. A client is brought to the emergency department after sustaining smoke inhalation injury during a fire in the client's home. What should the nurse plan to do first? Check for a patent IV line Provide emotional support to the client Provide the client with 100% oxygen by mask Administer intravenous (IV) fluids as prescribed - - correct ans- - Provide the client with 100% oxygen by mask Rationale: The nurse should first provide the client with 100% oxygen by mask. When smoke is inhaled, carbon monoxide binds with hemoglobin, displacing oxygen. A high carboxyhemoglobin level impairs tissue oxygenation, resulting in tissue asphyxia. Providing the client with 100% oxygen by mask reverses this condition. The nurse would next ensure that the client has a patent IV line and then administer fluids as prescribed. The nurse would also maintain body temperature, provide wound care as needed, and provide comfort and emotional support. A client with emphysema is receiving theophylline. While providing dietary instructions, what does the nurse tell the client is acceptable to consume? Cola Coffee Hot cocoa
Apple juice - - correct ans- - Apple juice Rationale: The nurse tells the client that apple juice is acceptable to consume. Theophylline is a methylxanthine bronchodilator. Caffeine is a methylxanthine with pharmacologic properties like those of theophylline. For this reason, caffeine can intensify the adverse effects of theophylline on the central nervous system and heart. In addition, caffeine competes with theophylline for drug-metabolizing enzymes, thereby causing the theophylline level to increase. Because of these interactions, individuals taking theophylline should avoid caffeine-containing beverages such as cola, coffee, tea, and cocoa, as well as other caffeine-containing products. Testing of the plasma theophylline level in a client who is receiving a continuous intravenous infusion of theophylline reveals a toxic level of 24 mcg/mL (111 umol/L). What early signs of toxicity does the nurse assess for? Select all that apply. Tremors Lethargy Bradycardia Palpitations Nervousness - - correct ans- - Tremors Palpitations Nervousness Rationale: Theophylline toxicity is likely to occur when the serum level is higher than 20 mcg/mL (111 mcmol/L). Early signs of toxicity include restlessness, not lethargy; nervousness; tremors; palpitations; and tachycardia, not bradycardia. The normal therapeutic range for theophylline is 10 to 20 mcg/mL (55.5 to 111 umol/L). Fluticasone propionate and albuterol, administered by inhalation twice daily, are prescribed for a client with asthma. The nurse provides information to the client about administration of the medication. What does the nurse tell the client about how to take the medications?
Report to the emergency department for treatment Get into the shower and rinse the skin for at least 15 minutes Go to the drugstore, purchase an over-the-counter topical corticosteroid, and rub it into the exposed skin - - correct ans- - Get into the shower and rinse the skin for at least 15 minutes Rationale: If contact with poison ivy is suspected, signs/symptoms may be averted by immediately rinsing the skin for 15 minutes with running water to remove the resin before skin penetration occurs. Persons walking or working in areas where poison ivy grows should protect the skin by wearing appropriate clothing. The client is also instructed to remove clothing carefully to avoid skin contact. Although a topical over- the-counter corticosteroid may relieve some of the discomfort of the poison ivy rash, this is not the action that needs to be taken immediately. Contacting the primary health care provider and coming to the emergency department for treatment are unnecessary. A nurse provides skin care instructions to a client with acne vulgaris. Which statement by the client indicates a need for further instruction? "I should use oil-based cosmetics." "I shouldn't leave make-up on overnight." "I should avoid rubbing my face vigorously." "I should wash my face two or three times a day with a mild cleanser." - - correct ans- - "I should use oil-based cosmetics." Rationale: There is a need for further instruction if the client states, "I should use oil- based cosmetics." The client with acne is instructed to use water-based cosmetics and to avoid exposure to skin products that contain oil, because products that are oily may cause flare-ups. The statements in the other options are correct. Oral candidiasis (thrush) develops in a client infected with HIV, and the nurse provides instruction to the client about measures to relieve the discomfort. Which statement by the client indicates a need for further instruction?
"I should avoid spicy foods." "I should eat foods with a soft texture." "I should use a soft-bristled toothbrush." "I should put ice in my drinks to help soothe the discomfort." - - correct ans- - "I should put ice in my drinks to help soothe the discomfort." Rationale: There is a need for further instruction if the client states, "I should put ice in my drinks to help soothe the discomfort." Oral candidiasis lesions make it difficult for the client to tolerate temperature extremes, so it is best for the client to consume foods and fluids that are tepid or room temperature rather than iced or hot. The other options are useful measures for alleviating the discomfort associated with this disorder. A client diagnosed with HIV infection who has been found to have histoplasmosis is being treated with intravenous amphotericin B. Which parameter does the nurse check to detect the most common adverse effect of this medication? Temperature Blood pressure Peripheral pulses Intake and output - - correct ans- - Intake and output Rationale: As a means of detecting renal injury, tests of kidney function should be performed weekly, and intake and output should be monitored closely. Amphotericin B, an antifungal medication, is highly toxic, and infusion reactions and renal damage occur, to varying degrees, in all clients. Other adverse effects include delirium, hypotension, hypertension, wheezing, and hypoxia. The remaining options are not associated with an adverse effect of the medication. A hospitalized client scheduled for surgery is told by the primary health care provider that he/she is extremely anemic and will need a blood transfusion. The client, a Jehovah's Witness, refuses the transfusion. What is the most appropriate initial nursing action?
