HESI Exit PN | HESI Exit PN Exam Version 2
Comprehensive Review | Questions with Correct
Answers and Expert Explanation for Each Question
| Nursing Exit Assessment
1. A nurse is caring for a client with heart failure who is prescribed digoxin 0.25 mg
daily. Which assessment finding should the nurse prioritize as a sign of digoxin
toxicity?
A. Occasional premature ventricular contractions
B. Visual disturbances such as seeing yellow-green halos
C. Heart rate of 78 beats per minute
D. Increased urine output following administration
Correct Answer: B
Expert Explanation: Digoxin is a cardiac glycoside that requires close monitoring
due to its narrow therapeutic index. Visual disturbances, particularly blurred vision
or yellow-green halos, are classic signs of toxicity that must be reported
immediately. The nurse must also monitor for gastrointestinal symptoms like
nausea and vomiting which often occur early in toxicity. Before administration, the
nurse always checks the apical pulse for one full minute to ensure it is at least 60
beats per minute. Providing timely assessment of these signs ensures patient safety
and prevents life-threatening arrhythmias.
,2. A client with Type 1 Diabetes Mellitus is found sweaty, shaky, and complaining of a
headache. What is the nurse’s first action?
A. Administer 15 grams of simple carbohydrates
B. Call the healthcare provider for an order of IV dextrose
C. Give 10 units of regular insulin subcutaneously
D. Check the client’s blood glucose level
Correct Answer: D
Expert Explanation: The client is exhibiting classic symptoms of hypoglycemia
which include diaphoresis, tremors, and headache. It is essential to confirm the
blood glucose level before implementing an intervention to ensure accuracy in
treatment. If the level is below 70 mg/dL, the nurse should then follow the 15-15
rule by providing simple sugars. Re-checking the glucose after 15 minutes is
necessary to see if the intervention was effective or if more sugar is needed.
Assessing the patient first allows the nurse to make a clinical decision based on
objective data.
3. The nurse is providing discharge instructions to a client with chronic obstructive
pulmonary disease (COPD). Which statement by the client indicates a need for further
teaching?
A. I should increase my oxygen flow to 6 L/min if I feel tired.
,B. I will use pursed-lip breathing when I feel short of breath.
C. I will eat small, frequent, high-calorie meals throughout the day.
D. I will avoid contact with people who have respiratory infections.
Correct Answer: A
Expert Explanation: Clients with COPD often rely on a hypoxic drive to breathe,
meaning high levels of oxygen can suppress their respiratory effort. Increasing
oxygen flow to 6 L/min without a prescription is dangerous and can lead to carbon
dioxide narcosis. Pursed-lip breathing and high-calorie small meals are appropriate
management strategies for maintaining energy and oxygenation. Avoiding infections
is critical as respiratory illnesses can cause severe exacerbations in COPD patients.
The nurse must ensure the client understands oxygen safety to prevent respiratory
failure at home.
4. A client is admitted with suspected appendicitis. Which physical assessment finding
should the nurse expect to document?
A. Pain in the left upper quadrant that radiates to the shoulder
B. Tenderness at McBurney’s point in the right lower quadrant
C. Relief of pain when applying firm pressure to the abdomen
D. Hyperactive bowel sounds in all four quadrants
, Correct Answer: B
Expert Explanation: Appendicitis typically presents with periumbilical pain that
later localizes to the right lower quadrant at McBurney’s point. Rebound tenderness
is a common sign where pain is felt more intensely when pressure is released rather
than applied. The nurse should also assess for fever, nausea, and a high white blood
cell count. Applying heat to the area is strictly contraindicated as it may cause the
appendix to rupture. Recognizing these symptoms early is vital for preventing
peritonitis and ensuring surgical intervention.
5. The nurse is monitoring a client receiving a blood transfusion. Ten minutes into the
infusion, the client reports chills and back pain. Which action should the nurse take
first?
A. Slow the infusion rate and notify the provider
B. Document the symptoms and continue the infusion
C. Administer diphenhydramine as prescribed for allergies
D. Stop the transfusion and disconnect the tubing
Correct Answer: D
Expert Explanation: Chills and back pain are hallmark signs of an acute hemolytic
transfusion reaction which is a medical emergency. The nurse must immediately
stop the transfusion and disconnect the blood tubing from the IV site to prevent
Comprehensive Review | Questions with Correct
Answers and Expert Explanation for Each Question
| Nursing Exit Assessment
1. A nurse is caring for a client with heart failure who is prescribed digoxin 0.25 mg
daily. Which assessment finding should the nurse prioritize as a sign of digoxin
toxicity?
A. Occasional premature ventricular contractions
B. Visual disturbances such as seeing yellow-green halos
C. Heart rate of 78 beats per minute
D. Increased urine output following administration
Correct Answer: B
Expert Explanation: Digoxin is a cardiac glycoside that requires close monitoring
due to its narrow therapeutic index. Visual disturbances, particularly blurred vision
or yellow-green halos, are classic signs of toxicity that must be reported
immediately. The nurse must also monitor for gastrointestinal symptoms like
nausea and vomiting which often occur early in toxicity. Before administration, the
nurse always checks the apical pulse for one full minute to ensure it is at least 60
beats per minute. Providing timely assessment of these signs ensures patient safety
and prevents life-threatening arrhythmias.
,2. A client with Type 1 Diabetes Mellitus is found sweaty, shaky, and complaining of a
headache. What is the nurse’s first action?
A. Administer 15 grams of simple carbohydrates
B. Call the healthcare provider for an order of IV dextrose
C. Give 10 units of regular insulin subcutaneously
D. Check the client’s blood glucose level
Correct Answer: D
Expert Explanation: The client is exhibiting classic symptoms of hypoglycemia
which include diaphoresis, tremors, and headache. It is essential to confirm the
blood glucose level before implementing an intervention to ensure accuracy in
treatment. If the level is below 70 mg/dL, the nurse should then follow the 15-15
rule by providing simple sugars. Re-checking the glucose after 15 minutes is
necessary to see if the intervention was effective or if more sugar is needed.
Assessing the patient first allows the nurse to make a clinical decision based on
objective data.
3. The nurse is providing discharge instructions to a client with chronic obstructive
pulmonary disease (COPD). Which statement by the client indicates a need for further
teaching?
A. I should increase my oxygen flow to 6 L/min if I feel tired.
,B. I will use pursed-lip breathing when I feel short of breath.
C. I will eat small, frequent, high-calorie meals throughout the day.
D. I will avoid contact with people who have respiratory infections.
Correct Answer: A
Expert Explanation: Clients with COPD often rely on a hypoxic drive to breathe,
meaning high levels of oxygen can suppress their respiratory effort. Increasing
oxygen flow to 6 L/min without a prescription is dangerous and can lead to carbon
dioxide narcosis. Pursed-lip breathing and high-calorie small meals are appropriate
management strategies for maintaining energy and oxygenation. Avoiding infections
is critical as respiratory illnesses can cause severe exacerbations in COPD patients.
The nurse must ensure the client understands oxygen safety to prevent respiratory
failure at home.
4. A client is admitted with suspected appendicitis. Which physical assessment finding
should the nurse expect to document?
A. Pain in the left upper quadrant that radiates to the shoulder
B. Tenderness at McBurney’s point in the right lower quadrant
C. Relief of pain when applying firm pressure to the abdomen
D. Hyperactive bowel sounds in all four quadrants
, Correct Answer: B
Expert Explanation: Appendicitis typically presents with periumbilical pain that
later localizes to the right lower quadrant at McBurney’s point. Rebound tenderness
is a common sign where pain is felt more intensely when pressure is released rather
than applied. The nurse should also assess for fever, nausea, and a high white blood
cell count. Applying heat to the area is strictly contraindicated as it may cause the
appendix to rupture. Recognizing these symptoms early is vital for preventing
peritonitis and ensuring surgical intervention.
5. The nurse is monitoring a client receiving a blood transfusion. Ten minutes into the
infusion, the client reports chills and back pain. Which action should the nurse take
first?
A. Slow the infusion rate and notify the provider
B. Document the symptoms and continue the infusion
C. Administer diphenhydramine as prescribed for allergies
D. Stop the transfusion and disconnect the tubing
Correct Answer: D
Expert Explanation: Chills and back pain are hallmark signs of an acute hemolytic
transfusion reaction which is a medical emergency. The nurse must immediately
stop the transfusion and disconnect the blood tubing from the IV site to prevent
