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HESI RN Exit Exam 2025: Comprehensive Practice
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Here are the multiple-choice questions and rationales for the provided answers: Question 1: The school nurse is called to the soccer field because a child has epistaxis. In which position should the nurse place the child? A) Side-lying with the head slightly elevated. B) Sitting up and leaning forward. C) Standing with the head leaning backwards. D) Supine with the legs raised. Correct Answer: B) Sitting up and leaning forward. Rationale: Sitting up and leaning forward helps to decrease venous pressure in the nasal vessels, reducing bleeding. Leaning forward prevents blood from flowing down the throat, which could lead to nausea or aspiration. Side-lying (A) doesn't directly address the bleeding mechanism. Leaning the head backwards (C) can cause blood to flow down the throat. Supine with legs raised (D) is used for hypotension or shock, not epistaxis. Question 2: The nurse is auscultating a clients lung sounds. Which description should the nurse use to document this sound? Please listen to the audio file to select the option that applies. A) High pitch squeeze. B) Rhonchi. C) High-pitched or fine crackles. D) Stridor. Correct Answer: C) High-pitched or fine crackles. Rationale: High-pitched or fine crackles are discontinuous, popping sounds heard during inspiration, often indicating fluid in the alveoli or atelectasis. The audio file (which I cannot directly access) is described as this type of sound. A high-pitched squeeze (A) describes wheezing. Rhonchi (B) are low-pitched, rumbling sounds often
associated with mucus in the larger airways. Stridor (D) is a high-pitched, harsh sound heard during inspiration, indicating upper airway obstruction. Question 3: NGN: Flow Sheet, vital signs, heart rate 104 bpm, respiratory rate 31 bpm. The client is experiencing __________________ and ____________________. Correct Answer: Tachypnea , tachycardia Rationale: A heart rate of 104 bpm is above the normal adult range (60-100 bpm), indicating tachycardia. A respiratory rate of 31 bpm is above the normal adult range (12- 20 breaths per minute), indicating tachypnea. Question 4: NGN: Orders, 1300 admit to the surgical unit, vital signs every four hours, advanced diet as tolerated, administer lactated ringers IV at 85 mL per hour, ibuprofen 800 mg PO every eight hours PRN for pain. (the nurse would anticipate which of the following could be affecting the clients current condition? SATA.) A) stress. B) Medication. C) Anemia. D) Fever. E) Hypothermia. F) Hypertension. G) Pain. Correct Answer: A) stress, B) Medication, G) Pain. Rationale:
- A) Stress: Admission to a surgical unit and a recent surgical procedure are stressful events that can affect vital signs.
- B) Medication: The effects of anesthesia and any other medications administered pre-operatively or intra-operatively could still be influencing the client's condition.
- G) Pain: Post-operative pain is a common occurrence and can elevate heart rate and respiratory rate.
D) Complete blood count. E) Urinalysis. F) Chest radiograph. G) Echocardiogram. Correct Answer: B) Blood gases, D) Complete blood count, F) Chest radiograph. Rationale:
- B) Blood gases: The order for supplemental oxygen at 2 L/min suggests a potential issue with oxygenation. Blood gases would provide information about the client's oxygenation, ventilation, and acid-base balance.
- D) Complete blood count: A CBC can provide baseline information about the client's overall health, including hemoglobin and hematocrit levels which could affect oxygen carrying capacity, and white blood cell count which could indicate infection (although not directly suggested by the initial orders).
- F) Chest radiograph: Given the post-operative status and the need for supplemental oxygen, a chest radiograph could help rule out pulmonary complications such as atelectasis or pneumonia. Doppler (A) is used to assess blood flow, blood culture (C) is used to identify infection, urinalysis (E) assesses kidney function and infection, and echocardiogram (G) assesses heart function; these are not directly indicated by the initial orders for a benign abdominal tumor removal but could be considered if further complications arise. Question 7: NGN: Nurses Notes, saturation is low. Noted cyanosis in the clients lips. Healthcare provider made aware. 1310: pain rating for on a pain scale of 0 to 10. Temperature elevation noted. The client is anxious and using accessory muscles to breathe. Alerted the surgeon about the client status. New orders noted. (what does the nurse need to document at 1330? SATA) A) urine output. B) Respiratory rate. C) Blood pressure. D) Pain. E) Temperature. F) Flow rate of oxygen.
G) Oxygen saturation. Correct Answer: B) Respiratory rate, C) Blood pressure, D) Pain, E) Temperature, G) Oxygen saturation. Rationale: The nurse needs to document the client's current status following the noted changes and the healthcare provider notification. This includes:
- B) Respiratory rate: The client is using accessory muscles, indicating respiratory distress, so the rate needs to be documented.
- C) Blood pressure: Changes in oxygenation and anxiety can affect blood pressure.
- D) Pain: Pain was assessed at 1310, and any changes should be documented.
- E) Temperature: A temperature elevation was noted.
- G) Oxygen saturation: The initial low saturation and cyanosis are critical findings that need to be reassessed and documented. While urine output (A) and flow rate of oxygen (F) are important, the immediate need is to document the key assessments related to the acute changes in the client's condition. However, if new oxygen orders were received, the flow rate should also be documented. Assuming new orders addressing oxygenation were likely received, F) Flow rate of oxygen should also be included. Revised Correct Answer: B) Respiratory rate, C) Blood pressure, D) Pain, E) Temperature, F) Flow rate of oxygen, G) Oxygen saturation. Question 8: NGN: Match the activity with the most appropriate person to do the activity.
- Document changes in respiratory status.
- Set up the oxygen administration system.
- Change the gauze under the nasal cannula. Correct Answer:
- Provide mouth care. (UAP) - Unlicensed Assistive Personnel (UAPs) are typically trained to provide basic hygiene care.
- Document changes in respiratory status. (RN/RT) - Registered Nurses (RNs) and Respiratory Therapists (RTs) are responsible for assessing and documenting changes in respiratory status due to their specialized knowledge.
decrease preload and afterload, and can slightly depress the respiratory center, which can be beneficial in reducing the work of breathing in pulmonary edema. Given the prescription and the clinical picture, the nurse should administer the morphine as ordered. Consulting the charge nurse (B) or reviewing with the provider (C) might be done if there were concerns about the appropriateness of the order, but morphine is a standard treatment for pulmonary edema. Withholding the medication (D) could delay necessary treatment. Question 11: A client with acute asthma exacerbation is manifesting inspiratory and expiratory wheezes and a decreased forced expiratory volume. Which prescribed drug class should the nurse administer first to the client? A) Inhaled short acting beta two agonists. B) Inhaled corticosteroids. C) Anti-cholinergics. D) Leukotriene modifiers. Correct Answer: A) Inhaled short acting beta two agonists. Rationale: In an acute asthma exacerbation characterized by wheezing and decreased airflow (decreased forced expiratory volume), the immediate goal is to bronchodilate the airways. Inhaled short-acting beta-2 agonists (SABAs) like albuterol provide rapid relief of bronchospasm by relaxing the smooth muscles in the airways. While inhaled corticosteroids (B) are important for long-term control of inflammation in asthma, they have a slower onset of action and are not the first-line treatment for acute symptoms. Anticholinergics (C) like ipratropium can be used in combination with SABAs for acute exacerbations, but SABAs are typically administered first. Leukotriene modifiers (D) are also for long-term control and prevention of asthma symptoms. Question 12: The nurse enters a clients room to administer oral medication's and find an unlicensed assistive personnel providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. Which is the priority nursing action? A) Determine why the UAP did not notify the nurse of the change in the clients condition. B) Advised the UAP to stop providing care so the nurse can assess the clients condition. C) Explain to the UAP that changes in a clients condition should be reported immediately.
D) Ask for UAP to position the client so the oral medication's can be administered. Correct Answer: B) Advised the UAP to stop providing care so the nurse can assess the clients condition. Rationale: The client's presentation (weak, pale, diaphoretic) indicates a significant change in condition that requires immediate assessment by the nurse. The priority is to assess the client's status and intervene as needed. Advising the UAP to stop care allows the nurse to immediately focus on the client's critical needs. While understanding why the change wasn't reported (A) and educating the UAP (C) are important follow-up actions, and positioning for medication (D) is irrelevant until the client is assessed and stable, the immediate priority is assessment. Question 13: The client who was admitted yesterday with severe dehydration is reporting pain where a 24 gauge IV catheter with 0.9% sodium chloride is infusing at a rate of 150 mL per hour. Which intervention should the nurse implement first? A) Discontinue the 24 gauge IV. B) Establish a second IV site. C) Stop the 0.9% sodium chloride infusion. D) Assess the IV for blood return. Correct Answer: C) Stop the 0.9% sodium chloride infusion. Rationale: Pain at the IV site can indicate infiltration (fluid leaking into surrounding tissue) or phlebitis (inflammation of the vein). Continuing the infusion could worsen these complications. Therefore, the first action should be to stop the infusion to prevent further tissue damage or irritation. After stopping the infusion, the nurse should then assess the IV site for signs of infiltration or phlebitis (D), and potentially discontinue the IV (A) and establish a new site (B) if indicated by the assessment. Question 14: Client should the nurse assess frequently because of the risk for overflow incontinence? A) a client with hematuria and decreasing hemoglobin and hematocrit levels. B) A client who has been fast, with increased serum creatinine levels. C) A client who is confused and frequently forgets to go to the bathroom. D) A client who has a history of frequent urinary tract infections.
A client develops your to Caria on the trunk and neck shortly after a secondary infusion of pepper Sillen is initiated. In which order should the nurse implement these interventions? Document reaction of the drug. Contact the healthcare provider. Assess vital signs. Stop the infusion. Initiate an adverse event report. - - correct ans- - Stop the infusion. Assess vital signs. Contact the healthcare provider. Initiate an adverse event report. Document reaction to drug. What nursing intervention is particularly indicated for the second stage of labor? A) Assessing the fetal heart rate and patterns for signs of fetal distress. B) Monitoring effects of oxytocin administration to help achieve cervical dilation. C) Providing pain medication to increase the clients tolerance of labor pains. D) Assisting the client to push effectively so that expulsion of the fetus can be achieved.
- correct ans- - D) Assisting the client to push effectively so that expulsion of the fetus can be achieved. A client receives a prescription for Aceta medicine 1000 mg PO every eight hours PRN for pain. The bottle is labeled acetaminophen for oral suspension, US P 500 mg per 15 mL. How many tablespoons should the nurse administer with each dose? (Enter numerical value only.) - - correct ans- - 2 15 mL per tablespoon
The nurse is administering multiple prescribe vaccines to a toddler. Which strategy should the nurse prioritized to reduce the duration of pain? A) Supine positioning. B) Verbal reassurance. C) Simultaneous injections. D) Physical soothing. - - correct ans- - C) Simultaneous injections. NGN: Dean 30, admit to the medical floor, vital signs every four hours, regular diet, out of bed with assist. Complete diagram with one condition, two actions, and two parameters. - - correct ans-
- Actions: the client for a nutrition history, encourage the client to drink Condition: Malnutrition Actions: ????? ???????? When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. Which action should the nurse implement first? A) Check for a distended bladder. B) Review the hemoglobin to determine hemorrhage. C) Increase IV infusion rate. D) Massage the uterus to decrease atony. - - correct ans- - A) Check for a distended bladder. A client who is receiving zidovudine reports the appearance of pinpoint, red, brown spots on the skin. Which result should the nurse report to the healthcare provider?
A client is receiving IV fluids by gravity infusion and exhibit signs of fluid volume overload. When assessing the clients IV delivery system, where should the nurse assess first? - - correct ans- - A I can't see all the pics. Use the clamp on the IV tubing. The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? SATA. A) Widen stance while working near the sink. B) Leans forward to pull a pan from a high shelf. C) Tenths from the waist to pick trash off the floor. D) Brings a heavy can close to body before lifting. E) Lots knees while preparing food on the counter. - - correct ans- - A) Widen stance while working near the sink. D) Brings a heavy can close to body before lifting. A client is receiving methylamine 800 mg PO three times a day. Which assessment should the nurse perform to assess the effectiveness of the medication? A) Bowel patterns. B) Pupillary response. C) Peripheral pulses. D) Oxygen saturation. - - correct ans- - A) Bowel patterns. Ulcerative colitis medication that helps reduce inflammation in the G.I..
Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspect the client may have had a pulmonary embolus. Which action should the nurse take first? A) Provide supplemental oxygen. B) Prepare a continuous heparin infusion per protocol. C) Bring the emergency craft cart to the bedside. D) Notify the healthcare provider. - - correct ans- - A) Provide supplemental oxygen. The nurse identifies an electrolyte imbalance, elevated blood pressure, and exhibited changes in mental status for a client with chronic kidney disease. Which is the most important action for the nurse to take? A) Monitor daily sodium intake. B) Auscultate for a regular heart rate. C) Document abdominal girth. D) Measure ankle circumference. - - correct ans- - B) Auscultate for a regular heart rate. The older adult client who has difficulty hearing is being discharged from the day surgeries following a cataract extraction and lens in plantation. Which intervention is most important for the nurse to implement to help ensure the client compliant with self- care? A) Ensure that someone will stay with the client for 24 hours. B) Have a client vocalize the instructions provided. C) Speak clearly and face the client for lip reading. D) Provide written instructions for eyedrop administration. - - correct ans- - B) Have a client vocalize the instructions provided. NO QUESTION 68 - - correct ans- -
D) Explain that this is a side effect of the medication in the patch. - - correct ans- - C) Notify the clients healthcare provider of the vomiting. This medication is used for nausea and the provider should be made aware if the medication is not effective. The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. Which action should the nurse take? SATA. A) Instruct the adult child to check the clients temperature. B) Encourage increased intake of high protein foods. C) Determine if the client has recently experienced a fall. D) Reviewed the clients current food and medication allergies. E) Ask if the client is experiencing any pain with urination. - - correct ans- - A) Instruct the adult child to check the clients temperature. C) Determine if the client has recently experienced a fall. E) Ask if the client is experiencing any pain with urination. The healthcare provider prescribes 30 survive for a four-year-old child who has a ventricular septal defect. Which outcome indicates to the nurse that this pharmacological intervention was effective? A) Urine specific gravity change from 1.0212 1.031. B) Urinary output decreases of 5 mL per hour. C) Daily weight decrease of 2 pounds. D) Blood urea nitrogen increase from 8 to 12. - - correct ans- - C) Daily weight decrease of 2 pounds. Lasix is a diarrhetic so there would not be a decrease in urine output, it is used for fluid retention so decreased weight would be appropriate.
NGN: Nurses Notes, 1800: the client is a female neonate born at 37 weeks of gestation to a gravida to party one mother, who was diagnosed with gestational diabetes following a spontaneous vaginal birth, she received Apgar scores of seven at one minute and eight at five minutes. The client weighs 8 lbs. 9 oz. and appears pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30.... The nurse recognizes that the infant of a diabetic mother is at risk for __________________, _________________________, and ___________________________. - - correct ans- - Hyperbilirubinemia , respiratory distress syndrome , cardiomyopathy NGN: (Nurses Notes)1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother, who was diagnosed with gestational diabetes. Following a spontaneous vaginal birth, she received Apgar scores of seven at one minute and eight at five minutes. The client weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30min of age. Axillary temperature 96F, ..... (For each assessment finding, click to indicate whether the findings are associated with an infant of a diabetic mother or normal presentation.)
- Mongolian spot.
- Acrocyanosis.
- Jittery at 30 minutes of age.
- Blood glucose 35.
- Billirubin 7.
- Respiratory rate 80 breaths per minute.
- Apgar 7 at one minute, 8 at five minutes.
- Soft fontanelles - - correct ans- --Mongolian spot. (NORMAL)
- Acrocyanosis. (NORMAL)
- Jittery at 30 minutes of age. (NOT NORMAL)
- Blood glucose 35. (NOT NORMAL)
- Billirubin 7. (NOT NORMAL)
A) Keep infant in warmer with Billirubin lights to maintain temp. B) Continue to monitor glucose levels. C) Observe for signs of respiratory distress and monitor oxygen. D) Tell the mother that she will need to discuss any concerns. E) Explain to the mother that the babies respiratory rate needs. F) Monitor temperature. G) Informed the mother that the baby is stable enough to take. - - correct ans- - B) Continue to monitor glucose levels. C) Observe for signs of respiratory distress and monitor oxygen. F) Monitor temperature. NGN - - correct ans- - NGN: day 2. 0630: Vitals have remained stable throughout the night. Oxygen 98% on 0.25 L per minute oxygen via nasal cannula. Mother to breast-feed in nursery on demand. Able to tolerate breastmilk. Glucose after feeding was 60, temp 97.8 F axillary when you return to warmer and Billy Rubin light. Chest x-ray and echocardiogram results were normal. Calcium and magnesium within normal limits. Direct bilirubin five. Discharge teaching initiated, with goal of discharging infant and mother on day three. Highlight notes that demonstrate improvement. - - correct ans- --Vitals have remained stable
- Oxygen 98% on 0.25 L per minute oxygen via nasal cannula
- Able to tolerate breastmilk.
- Glucose after feeding was 60, temp 97.8 F axillary
- Calcium and magnesium within normal limits.
- Direct bilirubin five The nurse discovers that an older adult client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this
electrolyte imbalance, which information is most important for the nurse to obtain from the clients medical history? A) length and frequency of the clients tobacco use. B) Genetically inherited disorders of family members. C) Frequency of laxative use for chronic constipation. D) Ingestion of shellfish or fish oil capsules daily. - - correct ans- - D) Ingestion of shellfish or fish oil capsules daily. Client who underwent an uncomplicated gastric bypass surgery is having difficulty with diet management. Which dietary instruction is most important for the nurse to explain to the client? A) To food slowly and thoroughly before attempting to swallow. B) Plan volume controlled, evenly space meals throughout the day. C) Sip fluids Chloe with each meal and between meals. D) Eliminate or reduce intake a fatty and gas forming foods. - - correct ans- - B) Plan volume controlled, evenly space meals throughout the day. A client with an acute myocardial infarction is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response? A) Activated partial thromboplastin (aPTT) time is two times the control value. B) Cardiac tracing shows 1.2 MM wide Q waves half the height of the complex. C) Guiac test of the stools is positive. D) S3 heart sounds are present with auscultation - - correct ans- - A) Activated partial thromboplastin (aPTT) time is two times the control value.
