HESI Exit Exam 202 Test Bank:
The Ultimate Study Guide with
Questions and Verified Answers for
2025/2026 to Ensure You Pass on
the First Try
1. A client with pneumonia is receiving oxygen at 2 L/min via nasal cannula. The
nurse should expect the oxygen saturation to be maintained at:
A. 80% to 85%
B. 86% to 88%
C. 92% or greater
D. 100% at all times
Answer: C. 92% or greater
Rationale: For a client with pneumonia, the goal of oxygen therapy is to maintain
adequate tissue oxygenation. An oxygen saturation of 92% or greater is generally
considered acceptable and indicates sufficient oxygen delivery. While 100% is ideal, it is
not always achievable or necessary, and maintaining it "at all times" is not a realistic
expectation.
2. A nurse is caring for a client receiving IV potassium. The nurse should monitor
for:
A. Cardiac arrhythmias
B. Increased urine output
C. Hypotension from fluid loss
D. Constipation
Answer: A. Cardiac arrhythmias
,Rationale: Intravenous potassium must be administered with extreme caution because
rapid infusion or high concentrations can lead to hyperkalemia. The most critical and
immediate complication of hyperkalemia is its effect on the heart, potentially causing
life-threatening cardiac arrhythmias, including peaked T waves, widened QRS, and
cardiac arrest.
3. A postpartum client reports burning on urination. The nurse should first:
A. Tell her to drink less fluid
B. Assess for urinary tract infection
C. Apply a warm compress to the abdomen
D. Encourage bed rest
Answer: B. Assess for urinary tract infection
Rationale: Dysuria (burning on urination) is a classic symptom of a urinary tract
infection (UTI), which is a common postpartum complication, often related to
catheterization during labor or bladder trauma. The nurse's first action should be to
further assess the client to gather more data, which may include obtaining a urine
sample for analysis and culture to confirm a UTI before implementing other
interventions.
4. A nurse is caring for a client with major depressive disorder. Which statement
indicates improvement?
A. "I still don't want to be around anyone."
B. "I am planning to attend my granddaughter's birthday."
C. "Nothing will ever change."
D. "I feel hopeless most of the time."
Answer: B. "I am planning to attend my granddaughter's birthday."
Rationale: Improvement in major depressive disorder is often signaled by a renewed
interest in life and future planning. Social withdrawal, hopelessness, and a fixed negative
mindset are all symptoms of depression. The client's ability to make a specific plan to
engage in a positive social event (the birthday) demonstrates a significant improvement
in mood, energy, and future orientation.
,5. A nurse is caring for a client receiving total parenteral nutrition (TPN). The
priority assessment is:
A. Blood glucose level
B. Bowel sounds
C. Skin turgor
D. Urine color
Answer: A. Blood glucose level
Rationale: TPN solutions are hypertonic and contain a high concentration of dextrose.
The sudden infusion of this high-glucose solution can cause severe hyperglycemia,
especially if the body is not producing enough insulin. Monitoring blood glucose levels
is the priority to prevent hyperglycemic hyperosmolar states. Other assessments are
relevant for overall nutrition and hydration but are not the immediate priority.
6. A client with COPD becomes short of breath while ambulating. The nurse should
first:
A. Have the client sit and use pursed-lip breathing
B. Administer IV fluids
C. Increase oxygen to 6 L/min
D. Apply a cooling blanket
Answer: A. Have the client sit and use pursed-lip breathing
Rationale: For a client with COPD experiencing shortness of breath on exertion, the
immediate priority is to reduce the work of breathing and improve gas exchange. Sitting
the client down reduces oxygen demand. Pursed-lip breathing helps keep airways open
longer during exhalation, which improves the elimination of carbon dioxide and is a
primary, non-pharmacologic intervention for dyspnea in COPD.
7. A nurse is teaching about oral contraceptives. Which finding requires immediate
follow-up?
A. Occasional nausea
B. Severe calf pain
C. Breast tenderness
, D. Mild weight gain
Answer: B. Severe calf pain
Rationale: Oral contraceptives carry a risk of thromboembolic events, including deep
vein thrombosis (DVT). Severe calf pain is a classic sign of a DVT, which can be life-
threatening if the clot dislodges and travels to the lungs (pulmonary embolism). This
requires immediate follow-up for diagnosis and treatment. Nausea, breast tenderness,
and mild weight gain are common, less urgent side effects.
8. A nurse is caring for a client with suspected meningitis. The nurse should
implement:
A. Contact precautions
B. Droplet precautions only during procedures
C. Droplet precautions until antibiotics are started
D. Airborne precautions at all times
Answer: C. Droplet precautions until antibiotics are started
Rationale: Bacterial meningitis (e.g., Neisseria meningitidis) is transmitted via large
droplets from the respiratory tract. Therefore, droplet precautions are required. These
precautions are maintained until the client has received effective antibiotics for at least
24-48 hours, after which they are no longer considered infectious.
9. The practical nurse (PN) selects the ventrogluteal site for an adult's IM injection.
Which is the correct location?
A. Upper outer quadrant of the buttock
B. Lateral aspect of upper thigh
C. Lateral hip (greater trochanter area)
D. Dorsogluteal
Answer: C. Lateral hip (greater trochanter area)
Rationale: The ventrogluteal site is located over the hip, specifically the greater
trochanter area. It is considered the safest site for intramuscular injections in adults
because it is free of major nerves and blood vessels and has a thick muscle mass.
The Ultimate Study Guide with
Questions and Verified Answers for
2025/2026 to Ensure You Pass on
the First Try
1. A client with pneumonia is receiving oxygen at 2 L/min via nasal cannula. The
nurse should expect the oxygen saturation to be maintained at:
A. 80% to 85%
B. 86% to 88%
C. 92% or greater
D. 100% at all times
Answer: C. 92% or greater
Rationale: For a client with pneumonia, the goal of oxygen therapy is to maintain
adequate tissue oxygenation. An oxygen saturation of 92% or greater is generally
considered acceptable and indicates sufficient oxygen delivery. While 100% is ideal, it is
not always achievable or necessary, and maintaining it "at all times" is not a realistic
expectation.
2. A nurse is caring for a client receiving IV potassium. The nurse should monitor
for:
A. Cardiac arrhythmias
B. Increased urine output
C. Hypotension from fluid loss
D. Constipation
Answer: A. Cardiac arrhythmias
,Rationale: Intravenous potassium must be administered with extreme caution because
rapid infusion or high concentrations can lead to hyperkalemia. The most critical and
immediate complication of hyperkalemia is its effect on the heart, potentially causing
life-threatening cardiac arrhythmias, including peaked T waves, widened QRS, and
cardiac arrest.
3. A postpartum client reports burning on urination. The nurse should first:
A. Tell her to drink less fluid
B. Assess for urinary tract infection
C. Apply a warm compress to the abdomen
D. Encourage bed rest
Answer: B. Assess for urinary tract infection
Rationale: Dysuria (burning on urination) is a classic symptom of a urinary tract
infection (UTI), which is a common postpartum complication, often related to
catheterization during labor or bladder trauma. The nurse's first action should be to
further assess the client to gather more data, which may include obtaining a urine
sample for analysis and culture to confirm a UTI before implementing other
interventions.
4. A nurse is caring for a client with major depressive disorder. Which statement
indicates improvement?
A. "I still don't want to be around anyone."
B. "I am planning to attend my granddaughter's birthday."
C. "Nothing will ever change."
D. "I feel hopeless most of the time."
Answer: B. "I am planning to attend my granddaughter's birthday."
Rationale: Improvement in major depressive disorder is often signaled by a renewed
interest in life and future planning. Social withdrawal, hopelessness, and a fixed negative
mindset are all symptoms of depression. The client's ability to make a specific plan to
engage in a positive social event (the birthday) demonstrates a significant improvement
in mood, energy, and future orientation.
,5. A nurse is caring for a client receiving total parenteral nutrition (TPN). The
priority assessment is:
A. Blood glucose level
B. Bowel sounds
C. Skin turgor
D. Urine color
Answer: A. Blood glucose level
Rationale: TPN solutions are hypertonic and contain a high concentration of dextrose.
The sudden infusion of this high-glucose solution can cause severe hyperglycemia,
especially if the body is not producing enough insulin. Monitoring blood glucose levels
is the priority to prevent hyperglycemic hyperosmolar states. Other assessments are
relevant for overall nutrition and hydration but are not the immediate priority.
6. A client with COPD becomes short of breath while ambulating. The nurse should
first:
A. Have the client sit and use pursed-lip breathing
B. Administer IV fluids
C. Increase oxygen to 6 L/min
D. Apply a cooling blanket
Answer: A. Have the client sit and use pursed-lip breathing
Rationale: For a client with COPD experiencing shortness of breath on exertion, the
immediate priority is to reduce the work of breathing and improve gas exchange. Sitting
the client down reduces oxygen demand. Pursed-lip breathing helps keep airways open
longer during exhalation, which improves the elimination of carbon dioxide and is a
primary, non-pharmacologic intervention for dyspnea in COPD.
7. A nurse is teaching about oral contraceptives. Which finding requires immediate
follow-up?
A. Occasional nausea
B. Severe calf pain
C. Breast tenderness
, D. Mild weight gain
Answer: B. Severe calf pain
Rationale: Oral contraceptives carry a risk of thromboembolic events, including deep
vein thrombosis (DVT). Severe calf pain is a classic sign of a DVT, which can be life-
threatening if the clot dislodges and travels to the lungs (pulmonary embolism). This
requires immediate follow-up for diagnosis and treatment. Nausea, breast tenderness,
and mild weight gain are common, less urgent side effects.
8. A nurse is caring for a client with suspected meningitis. The nurse should
implement:
A. Contact precautions
B. Droplet precautions only during procedures
C. Droplet precautions until antibiotics are started
D. Airborne precautions at all times
Answer: C. Droplet precautions until antibiotics are started
Rationale: Bacterial meningitis (e.g., Neisseria meningitidis) is transmitted via large
droplets from the respiratory tract. Therefore, droplet precautions are required. These
precautions are maintained until the client has received effective antibiotics for at least
24-48 hours, after which they are no longer considered infectious.
9. The practical nurse (PN) selects the ventrogluteal site for an adult's IM injection.
Which is the correct location?
A. Upper outer quadrant of the buttock
B. Lateral aspect of upper thigh
C. Lateral hip (greater trochanter area)
D. Dorsogluteal
Answer: C. Lateral hip (greater trochanter area)
Rationale: The ventrogluteal site is located over the hip, specifically the greater
trochanter area. It is considered the safest site for intramuscular injections in adults
because it is free of major nerves and blood vessels and has a thick muscle mass.
