HESI Exit RN V3 |160 Questions with 100% Correct
Answers | Latest Version (2026/2027) Expert Verified
A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a
nasogastric tube to suction and is receiving Lactated Ringer's solution at 75
mL/hour IV. One
hour after admission to the unit, the nurse notes 300 mL of blood in the
suction canister, the
client's heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg.
In addition to
reporting the finding to the surgeon. Which action should the nurse
implement first?
a. Measure and document the client's urinary output.
b. Request the client's reserved unit if packed red blood cells.
c. Prepare the placement of a central venous catheter.
d. Increase the infusion rate of Lactated Ringer's solution -
Correct Answer-d. Increase the infusion rate of Lactated Ringer's solution
an adult male who fell 20 feet from the roof of this home has multiple injuries,
including a right
pneumothorax. Chest tubes were inserted in the emergency department
prior to his transfer to
, the intensive care unit (ICU). the nurse notes that the suction control chamber
is bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour
75 ml of bright red
blood is measured in the collection chamber. Which intervention should the
nurse implement?
a. Add sterile water to the suction control chamber.
b. Give blood from the collection chamber as autotransfusion
c. Manipulate blood in tubing to drain into chamber.
d. Increase wall suction to eliminate fluctuation in water seal -
Correct Answer-a. Add sterile water to the suction control chamber.
A client who received hemodialysis yesterday is experiencing a blood pressure
of 200/100
mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute.
The client is
manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen
saturation on room air
of 89%. Which action should the nurse take first?
a. Elevate the foot of the bed.
b. Restrict the client's fluid.
c. Begin supplemental oxygen.
d. Prepare the client for hemodialysis. -
Correct Answer-c. Begin supplemental oxygen.
The correct answer is c. Begin supplemental oxygen.
In nursing prioritization (often using the ABC—Airway, Breathing, Circulation—framework), life-threatening
respiratory distress must be addressed immediately.
Rationale
The Critical Problem: The client is showing signs of Fluid Volume Overload (likely pulmonary edema),
evidenced by the high blood pressure, pedal edema, and—most critically—an oxygen saturation (
, ) of 89% and a respiratory rate of 36 breaths/minute.
Why Oxygen First? An
below 90% indicates significant hypoxia. Providing supplemental oxygen is the fastest way to stabilize the
client’s oxygenation and reduce the workload on the heart and lungs.
A client with Addison's crisis is admitted for treatment with adrenal cortical
supplementation.
, Based on the client's admitting diagnosis, which findings require immediate
action by the nurse?
(Select all that apply)
a. Headache and tremors
b. Irregular heart rate
c. Skin hyperpigmentation
d. Postural hypotension
e. Pallor and diaphoresis -
Correct Answer-a. Headache and tremors
b. Irregular heart rate
e. Pallor and diaphoresis
An older client is admitted with fluid volume deficit and dehydration. Which
assessment finding
is the best indicator of hydration that the nurse should report to the
healthcare provider?
a. Urine specific gravity is 1.040
b. Systolic blood pressure decreases 10 points when standing.
c. The client denies being thirsty.
d. Skin tenting occurs when the client's forearm is pinched. -
Correct Answer-d. Skin tenting occurs when the client's forearm is pinched.
After an inservice about electronic health record (EHR) security and
safeguarding client
information, the nurse observes a colleague going home with printed copies of
client
information in a uniform pocket. Which action should the nurse take?
Answers | Latest Version (2026/2027) Expert Verified
A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a
nasogastric tube to suction and is receiving Lactated Ringer's solution at 75
mL/hour IV. One
hour after admission to the unit, the nurse notes 300 mL of blood in the
suction canister, the
client's heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg.
In addition to
reporting the finding to the surgeon. Which action should the nurse
implement first?
a. Measure and document the client's urinary output.
b. Request the client's reserved unit if packed red blood cells.
c. Prepare the placement of a central venous catheter.
d. Increase the infusion rate of Lactated Ringer's solution -
Correct Answer-d. Increase the infusion rate of Lactated Ringer's solution
an adult male who fell 20 feet from the roof of this home has multiple injuries,
including a right
pneumothorax. Chest tubes were inserted in the emergency department
prior to his transfer to
, the intensive care unit (ICU). the nurse notes that the suction control chamber
is bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour
75 ml of bright red
blood is measured in the collection chamber. Which intervention should the
nurse implement?
a. Add sterile water to the suction control chamber.
b. Give blood from the collection chamber as autotransfusion
c. Manipulate blood in tubing to drain into chamber.
d. Increase wall suction to eliminate fluctuation in water seal -
Correct Answer-a. Add sterile water to the suction control chamber.
A client who received hemodialysis yesterday is experiencing a blood pressure
of 200/100
mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute.
The client is
manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen
saturation on room air
of 89%. Which action should the nurse take first?
a. Elevate the foot of the bed.
b. Restrict the client's fluid.
c. Begin supplemental oxygen.
d. Prepare the client for hemodialysis. -
Correct Answer-c. Begin supplemental oxygen.
The correct answer is c. Begin supplemental oxygen.
In nursing prioritization (often using the ABC—Airway, Breathing, Circulation—framework), life-threatening
respiratory distress must be addressed immediately.
Rationale
The Critical Problem: The client is showing signs of Fluid Volume Overload (likely pulmonary edema),
evidenced by the high blood pressure, pedal edema, and—most critically—an oxygen saturation (
, ) of 89% and a respiratory rate of 36 breaths/minute.
Why Oxygen First? An
below 90% indicates significant hypoxia. Providing supplemental oxygen is the fastest way to stabilize the
client’s oxygenation and reduce the workload on the heart and lungs.
A client with Addison's crisis is admitted for treatment with adrenal cortical
supplementation.
, Based on the client's admitting diagnosis, which findings require immediate
action by the nurse?
(Select all that apply)
a. Headache and tremors
b. Irregular heart rate
c. Skin hyperpigmentation
d. Postural hypotension
e. Pallor and diaphoresis -
Correct Answer-a. Headache and tremors
b. Irregular heart rate
e. Pallor and diaphoresis
An older client is admitted with fluid volume deficit and dehydration. Which
assessment finding
is the best indicator of hydration that the nurse should report to the
healthcare provider?
a. Urine specific gravity is 1.040
b. Systolic blood pressure decreases 10 points when standing.
c. The client denies being thirsty.
d. Skin tenting occurs when the client's forearm is pinched. -
Correct Answer-d. Skin tenting occurs when the client's forearm is pinched.
After an inservice about electronic health record (EHR) security and
safeguarding client
information, the nurse observes a colleague going home with printed copies of
client
information in a uniform pocket. Which action should the nurse take?
