HESI PN EXIT EXAM V1 COMPLETE 300+ QUESTIONS WITH 100% VERIFIED
ANSWERS AND DETAILED RATIONALES
Question 1
The nurse is caring for a client following a thyroidectomy. The client reports
tingling around the mouth and in the fingers. Which laboratory value should the
nurse check first?
A. Serum calcium
B. Serum potassium
C. Serum sodium
D. Serum magnesium
CORRECT ANSWER: A
RATIONALE: Tingling around the mouth and fingers (paresthesia) is an early sign of
hypocalcemia, which can occur after thyroidectomy if the parathyroid glands are
accidentally removed or damaged. Hypocalcemia can lead to tetany and
laryngospasm. The nurse should check serum calcium immediately.
Question 2
A client with heart failure is prescribed furosemide (Lasix) 40 mg orally twice daily.
Which finding indicates the medication is having the desired effect?
A. Weight loss of 2 pounds in 24 hours
B. Heart rate 110 beats per minute
C. Blood pressure 90/60 mm Hg
D. Crackles auscultated in lung bases
CORRECT ANSWER: A
RATIONALE: Furosemide is a loop diuretic that removes excess fluid. Weight loss of
2 pounds in 24 hours indicates fluid loss (1 pound = approximately 500 mL of
,fluid). Crackles indicate fluid overload (worsening, not improvement). Tachycardia
and hypotension may indicate dehydration or hypovolemia.
Question 3
The nurse is reinforcing teaching with a client who has a new prescription for
warfarin (Coumadin). Which over-the-counter medication should the client avoid?
A. Acetaminophen (Tylenol)
B. Ibuprofen (Advil)
C. Loratadine (Claritin)
D. Diphenhydramine (Benadryl)
CORRECT ANSWER: B
RATIONALE: Ibuprofen (an NSAID) increases the risk of bleeding when taken with
warfarin and should be avoided. Acetaminophen is safer but should still be used
cautiously. Antihistamines do not interact significantly with warfarin.
Question 4
A client with type 1 diabetes mellitus is admitted with diabetic ketoacidosis (DKA).
The nurse expects which finding during assessment?
A. Blood glucose 60 mg/dL and cool, clammy skin
B. Blood glucose 500 mg/dL and deep, rapid respirations
C. Blood glucose 120 mg/dL and bradycardia
D. Blood glucose 300 mg/dL and slow, shallow respirations
CORRECT ANSWER: B
RATIONALE: DKA causes severe hyperglycemia (often >250 mg/dL) and metabolic
acidosis, leading to Kussmaul respirations (deep, rapid breathing) as
compensation. Cool, clammy skin and hypoglycemia suggest insulin reaction. Slow,
shallow respirations are not compensatory.
,Question 5
The nurse is caring for a client receiving a blood transfusion. Fifteen minutes after
the transfusion begins, the client reports low back pain and chills. What is the
nurse's priority action?
A. Slow the infusion rate to 50 mL/hour
B. Stop the transfusion immediately
C. Administer acetaminophen as prescribed
D. Notify the healthcare provider
CORRECT ANSWER: B
RATIONALE: Low back pain and chills are signs of a hemolytic transfusion reaction.
The nurse must stop the transfusion immediately to prevent further reaction. The
IV line should be kept open with normal saline and new tubing. The healthcare
provider is notified after stopping the transfusion.
Question 6
A client with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 86% on room air. The nurse should anticipate an order for oxygen at
which flow rate?
A. 1-2 L/min via nasal cannula
B. 4-6 L/min via nasal cannula
C. 8-10 L/min via simple face mask
D. 10-12 L/min via non-rebreather mask
CORRECT ANSWER: A
RATIONALE: Clients with COPD may have chronic carbon dioxide retention and rely
on hypoxic drive for stimulation of breathing. High-flow oxygen can suppress the
respiratory drive and cause CO2 narcosis. Low-flow oxygen (1-2 L/min) is
prescribed to maintain saturation at 88-92%.
, Question 7
The nurse is caring for a client with a new colostomy. Which finding should be
reported to the healthcare provider immediately?
A. The stoma is bright red and moist
B. The stoma is dark purple and edematous
C. The stoma is slightly swollen and pink
D. The stoma has a small amount of serous drainage
CORRECT ANSWER: B
RATIONALE: A healthy stoma should be bright red to pink and moist. A dark purple
or bluish stoma indicates ischemia or necrosis due to compromised blood supply.
This is an emergency requiring immediate notification. Slight swelling and pink
color are normal postoperatively.
Question 8
A client with a head injury has a Glasgow Coma Scale (GCS) score of 6. The nurse
should interpret this as indicating which level of consciousness?
A. Alert and oriented
B. Lethargic but arousable
C. Severe brain injury with coma
D. Persistent vegetative state
CORRECT ANSWER: C
RATIONALE: A GCS score of 8 or less indicates severe brain injury and coma. The
client does not open eyes, does not follow commands, and may have abnormal
motor responses. A normal GCS is 15.
Question 9
ANSWERS AND DETAILED RATIONALES
Question 1
The nurse is caring for a client following a thyroidectomy. The client reports
tingling around the mouth and in the fingers. Which laboratory value should the
nurse check first?
A. Serum calcium
B. Serum potassium
C. Serum sodium
D. Serum magnesium
CORRECT ANSWER: A
RATIONALE: Tingling around the mouth and fingers (paresthesia) is an early sign of
hypocalcemia, which can occur after thyroidectomy if the parathyroid glands are
accidentally removed or damaged. Hypocalcemia can lead to tetany and
laryngospasm. The nurse should check serum calcium immediately.
Question 2
A client with heart failure is prescribed furosemide (Lasix) 40 mg orally twice daily.
Which finding indicates the medication is having the desired effect?
A. Weight loss of 2 pounds in 24 hours
B. Heart rate 110 beats per minute
C. Blood pressure 90/60 mm Hg
D. Crackles auscultated in lung bases
CORRECT ANSWER: A
RATIONALE: Furosemide is a loop diuretic that removes excess fluid. Weight loss of
2 pounds in 24 hours indicates fluid loss (1 pound = approximately 500 mL of
,fluid). Crackles indicate fluid overload (worsening, not improvement). Tachycardia
and hypotension may indicate dehydration or hypovolemia.
Question 3
The nurse is reinforcing teaching with a client who has a new prescription for
warfarin (Coumadin). Which over-the-counter medication should the client avoid?
A. Acetaminophen (Tylenol)
B. Ibuprofen (Advil)
C. Loratadine (Claritin)
D. Diphenhydramine (Benadryl)
CORRECT ANSWER: B
RATIONALE: Ibuprofen (an NSAID) increases the risk of bleeding when taken with
warfarin and should be avoided. Acetaminophen is safer but should still be used
cautiously. Antihistamines do not interact significantly with warfarin.
Question 4
A client with type 1 diabetes mellitus is admitted with diabetic ketoacidosis (DKA).
The nurse expects which finding during assessment?
A. Blood glucose 60 mg/dL and cool, clammy skin
B. Blood glucose 500 mg/dL and deep, rapid respirations
C. Blood glucose 120 mg/dL and bradycardia
D. Blood glucose 300 mg/dL and slow, shallow respirations
CORRECT ANSWER: B
RATIONALE: DKA causes severe hyperglycemia (often >250 mg/dL) and metabolic
acidosis, leading to Kussmaul respirations (deep, rapid breathing) as
compensation. Cool, clammy skin and hypoglycemia suggest insulin reaction. Slow,
shallow respirations are not compensatory.
,Question 5
The nurse is caring for a client receiving a blood transfusion. Fifteen minutes after
the transfusion begins, the client reports low back pain and chills. What is the
nurse's priority action?
A. Slow the infusion rate to 50 mL/hour
B. Stop the transfusion immediately
C. Administer acetaminophen as prescribed
D. Notify the healthcare provider
CORRECT ANSWER: B
RATIONALE: Low back pain and chills are signs of a hemolytic transfusion reaction.
The nurse must stop the transfusion immediately to prevent further reaction. The
IV line should be kept open with normal saline and new tubing. The healthcare
provider is notified after stopping the transfusion.
Question 6
A client with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 86% on room air. The nurse should anticipate an order for oxygen at
which flow rate?
A. 1-2 L/min via nasal cannula
B. 4-6 L/min via nasal cannula
C. 8-10 L/min via simple face mask
D. 10-12 L/min via non-rebreather mask
CORRECT ANSWER: A
RATIONALE: Clients with COPD may have chronic carbon dioxide retention and rely
on hypoxic drive for stimulation of breathing. High-flow oxygen can suppress the
respiratory drive and cause CO2 narcosis. Low-flow oxygen (1-2 L/min) is
prescribed to maintain saturation at 88-92%.
, Question 7
The nurse is caring for a client with a new colostomy. Which finding should be
reported to the healthcare provider immediately?
A. The stoma is bright red and moist
B. The stoma is dark purple and edematous
C. The stoma is slightly swollen and pink
D. The stoma has a small amount of serous drainage
CORRECT ANSWER: B
RATIONALE: A healthy stoma should be bright red to pink and moist. A dark purple
or bluish stoma indicates ischemia or necrosis due to compromised blood supply.
This is an emergency requiring immediate notification. Slight swelling and pink
color are normal postoperatively.
Question 8
A client with a head injury has a Glasgow Coma Scale (GCS) score of 6. The nurse
should interpret this as indicating which level of consciousness?
A. Alert and oriented
B. Lethargic but arousable
C. Severe brain injury with coma
D. Persistent vegetative state
CORRECT ANSWER: C
RATIONALE: A GCS score of 8 or less indicates severe brain injury and coma. The
client does not open eyes, does not follow commands, and may have abnormal
motor responses. A normal GCS is 15.
Question 9
