HESI Exit PN | HESI Exit PN Exam Version 7
Comprehensive Review | Questions with Correct
Answers and Expert Explanation for Each Question
| Nursing Exit Assessment
1. A nurse is caring for a client with congestive heart failure who is receiving digoxin
and furosemide. The client reports seeing yellow halos around lights and feeling
nauseated. Which action should the nurse take first?
A. Administer the scheduled dose of furosemide as prescribed.
B. Assess the client’s apical pulse and withhold the digoxin.
C. Encourage the client to increase intake of potassium-rich foods.
D. Document the findings as a common side effect of heart failure.
Correct Answer: B
Expert Explanation: The client’s reports of yellow halos and nausea are hallmark
signs of digoxin toxicity. Digoxin has a narrow therapeutic range, and toxicity is
often exacerbated by hypokalemia from diuretics like furosemide. The nurse must
prioritize patient safety by checking the apical pulse for one full minute. If the heart
rate is outside the prescribed parameters, the medication should be withheld
immediately. The healthcare provider must be notified to evaluate serum digoxin
and electrolyte levels.
,2. A nurse is assessing a 4-week-old infant suspected of having hypertrophic pyloric
stenosis. Which clinical manifestation should the nurse expect to observe?
A. Currant jelly-like stools containing blood and mucus.
B. Increased appetite followed by chronic diarrhea.
C. Abdominal distention and bile-stained emesis.
D. Projectile vomiting immediately after feeding.
Correct Answer: D
Expert Explanation: Hypertrophic pyloric stenosis is characterized by an olive-
shaped mass in the epigastrium and projectile vomiting. This condition typically
manifests in the first few weeks of life as the pyloric sphincter thickens. The infant
will often appear hungry immediately after vomiting because the food never
reached the small intestine. Chronic metabolic alkalosis can develop due to the
significant loss of gastric acid through vomiting. The nurse should also monitor the
infant closely for signs of dehydration and electrolyte imbalances.
3. A client at 34 weeks of gestation is admitted to the labor and delivery unit with a
diagnosis of preeclampsia. Which assessment finding is most concerning to the nurse?
A. Peripheral edema in the lower extremities.
B. A reported sudden onset of a severe headache.
C. A blood pressure reading of 148/92 mmHg.
,D. Presence of 1+ protein in the urine sample.
Correct Answer: B
Expert Explanation: A severe headache in a client with preeclampsia is a warning
sign of central nervous system irritability. This symptom often precedes the onset of
seizures, which would shift the diagnosis to eclampsia. While edema and elevated
blood pressure are common in preeclampsia, they are not as immediately life-
threatening as seizure risk. The nurse must maintain a quiet environment and
prepare for the administration of magnesium sulfate. Continuous monitoring of fetal
heart rate and maternal vital signs is essential for safety.
4. A nurse is preparing to administer lithium carbonate to a client with bipolar
disorder. Which laboratory value should the nurse review before giving the
medication?
A. Glycosylated hemoglobin (HbA1c).
B. Prothrombin time and INR.
C. Serum amylase and lipase.
D. Serum creatinine and BUN levels.
Correct Answer: D
Expert Explanation: Lithium is excreted primarily by the kidneys, so renal function
must be adequate to prevent toxicity. Elevated creatinine and BUN levels indicate
, impaired kidney function, which would cause lithium to accumulate to dangerous
levels. The therapeutic index for lithium is very narrow, requiring frequent serum
monitoring. The nurse should also ensure the client has adequate sodium and fluid
intake to maintain stability. Any signs of toxicity, such as tremors or confusion, must
be reported to the provider immediately.
5. After receiving a change-of-shift report, which client should the nurse assess first?
A. A client with a chest tube who has 50 mL of drainage in the last hour.
B. A client with COPD who is experiencing increased shortness of breath and
agitation.
C. A client 2 hours post-op from a total hip replacement complaining of leg pain.
D. A client with diabetes whose morning blood glucose is 110 mg/dL.
Correct Answer: B
Expert Explanation: The client with COPD experiencing agitation and dyspnea may
be suffering from acute respiratory distress or hypoxia. Agitation is often an early
sign of decreased oxygenation in the brain. Using the ABC (Airway, Breathing,
Circulation) framework, this client represents the highest priority for intervention.
The nurse needs to assess oxygen saturation levels and lung sounds immediately.
While post-operative pain is important, it does not take precedence over an acute
respiratory compromise.
Comprehensive Review | Questions with Correct
Answers and Expert Explanation for Each Question
| Nursing Exit Assessment
1. A nurse is caring for a client with congestive heart failure who is receiving digoxin
and furosemide. The client reports seeing yellow halos around lights and feeling
nauseated. Which action should the nurse take first?
A. Administer the scheduled dose of furosemide as prescribed.
B. Assess the client’s apical pulse and withhold the digoxin.
C. Encourage the client to increase intake of potassium-rich foods.
D. Document the findings as a common side effect of heart failure.
Correct Answer: B
Expert Explanation: The client’s reports of yellow halos and nausea are hallmark
signs of digoxin toxicity. Digoxin has a narrow therapeutic range, and toxicity is
often exacerbated by hypokalemia from diuretics like furosemide. The nurse must
prioritize patient safety by checking the apical pulse for one full minute. If the heart
rate is outside the prescribed parameters, the medication should be withheld
immediately. The healthcare provider must be notified to evaluate serum digoxin
and electrolyte levels.
,2. A nurse is assessing a 4-week-old infant suspected of having hypertrophic pyloric
stenosis. Which clinical manifestation should the nurse expect to observe?
A. Currant jelly-like stools containing blood and mucus.
B. Increased appetite followed by chronic diarrhea.
C. Abdominal distention and bile-stained emesis.
D. Projectile vomiting immediately after feeding.
Correct Answer: D
Expert Explanation: Hypertrophic pyloric stenosis is characterized by an olive-
shaped mass in the epigastrium and projectile vomiting. This condition typically
manifests in the first few weeks of life as the pyloric sphincter thickens. The infant
will often appear hungry immediately after vomiting because the food never
reached the small intestine. Chronic metabolic alkalosis can develop due to the
significant loss of gastric acid through vomiting. The nurse should also monitor the
infant closely for signs of dehydration and electrolyte imbalances.
3. A client at 34 weeks of gestation is admitted to the labor and delivery unit with a
diagnosis of preeclampsia. Which assessment finding is most concerning to the nurse?
A. Peripheral edema in the lower extremities.
B. A reported sudden onset of a severe headache.
C. A blood pressure reading of 148/92 mmHg.
,D. Presence of 1+ protein in the urine sample.
Correct Answer: B
Expert Explanation: A severe headache in a client with preeclampsia is a warning
sign of central nervous system irritability. This symptom often precedes the onset of
seizures, which would shift the diagnosis to eclampsia. While edema and elevated
blood pressure are common in preeclampsia, they are not as immediately life-
threatening as seizure risk. The nurse must maintain a quiet environment and
prepare for the administration of magnesium sulfate. Continuous monitoring of fetal
heart rate and maternal vital signs is essential for safety.
4. A nurse is preparing to administer lithium carbonate to a client with bipolar
disorder. Which laboratory value should the nurse review before giving the
medication?
A. Glycosylated hemoglobin (HbA1c).
B. Prothrombin time and INR.
C. Serum amylase and lipase.
D. Serum creatinine and BUN levels.
Correct Answer: D
Expert Explanation: Lithium is excreted primarily by the kidneys, so renal function
must be adequate to prevent toxicity. Elevated creatinine and BUN levels indicate
, impaired kidney function, which would cause lithium to accumulate to dangerous
levels. The therapeutic index for lithium is very narrow, requiring frequent serum
monitoring. The nurse should also ensure the client has adequate sodium and fluid
intake to maintain stability. Any signs of toxicity, such as tremors or confusion, must
be reported to the provider immediately.
5. After receiving a change-of-shift report, which client should the nurse assess first?
A. A client with a chest tube who has 50 mL of drainage in the last hour.
B. A client with COPD who is experiencing increased shortness of breath and
agitation.
C. A client 2 hours post-op from a total hip replacement complaining of leg pain.
D. A client with diabetes whose morning blood glucose is 110 mg/dL.
Correct Answer: B
Expert Explanation: The client with COPD experiencing agitation and dyspnea may
be suffering from acute respiratory distress or hypoxia. Agitation is often an early
sign of decreased oxygenation in the brain. Using the ABC (Airway, Breathing,
Circulation) framework, this client represents the highest priority for intervention.
The nurse needs to assess oxygen saturation levels and lung sounds immediately.
While post-operative pain is important, it does not take precedence over an acute
respiratory compromise.
