BSN 366 HESI RN Exit Exam V3 (2025/2026) Questions and 100% Verified
Answers
Medical-Surgical Nursing (1-30)
1. A client with heart failure is prescribed furosemide (Lasix). Which laboratory value should the
nurse monitor most closely?
o A) Potassium 3.0 mEq/L
o Rationale: Furosemide is a loop diuretic that causes potassium wasting. Hypokalemia
(potassium < 3.5 mEq/L) can precipitate cardiac dysrhythmias.
2. A client who had a total hip replacement 2 days ago reports sudden shortness of breath and
chest pain. What is the nurse's priority action?
o C) Call the rapid response team
o Rationale: Sudden shortness of breath and chest pain in a post-operative orthopedic
patient are classic signs of a pulmonary embolism (PE), a life-threatening emergency.
3. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 4 L/min via
nasal cannula. The nurse notes the client appears drowsy and has a respiratory rate of 8
breaths per minute. What is the nurse's priority action?
o B) Decrease the oxygen flow rate
o Rationale: The client is exhibiting signs of oxygen-induced hypercapnic respiratory
failure (CO2 narcosis).
4. A client with cirrhosis develops ascites. Which dietary modification is most appropriate?
o B) Restrict sodium intake to 2 g per day
o Rationale: Ascites in cirrhosis is caused by portal hypertension and sodium retention.
Sodium restriction is the first-line dietary intervention.
5. A client receiving chemotherapy develops stomatitis. Which intervention should the nurse
include in the plan of care?
o C) Recommend a soft-bristled toothbrush for oral hygiene
o Rationale: A soft-bristled toothbrush minimizes trauma to the inflamed oral mucosa.
, 6. Four hours following surgical repair of a compound fracture of the right ulna, the nurse is
unable to palpate the client's right radial pulse. Which action should the nurse take first?
o Elevate the client's right hand on one or two pillows
o Rationale: This helps reduce swelling that may be compressing the artery.
7. The nurse is reviewing the laboratory values for a client with acute pancreatitis who reports the
abdominal pain is not as severe as it was on admission. Which laboratory test should the nurse
review to evaluate the client's clinical recovery?
o Lipase
o Rationale: Lipase is more specific to the pancreas and remains elevated longer than
amylase, making it a better indicator of pancreatic inflammation.
8. While assessing a client who had a laparotomy the previous day, the nurse notices that 300 mL
of dark red fluid has drained from the nasogastric tube in the last hour. Which action should
the nurse take first?
o Take vital signs
o Rationale: Dark red drainage indicates active bleeding requiring immediate assessment
of hemodynamic status.
9. A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating Kussmaul breathing
and has a severe headache along with nausea. Her arterial blood gases (ABG) are: pH 7.50;
PaCO2 30 mmHg; HCO3 24 mEq/L. Which assessment finding warrants immediate intervention
by the nurse?
o Fruity breath
o Rationale: Fruity breath indicates ketone production, requiring immediate intervention.
10. As part of the treatment plan for a client diagnosed with acute pancreatitis, the nurse plans to
withhold oral fluids based on which pathophysiological process?
o Decreasing the formation and secretion of pancreatic enzymes
o Rationale: Resting the pancreas by withholding oral fluids and providing IV fluids
decreases pancreatic enzyme secretion.
11. The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and
massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?
o Hypoalbuminemia that results in a decreased colloidal oncotic pressure
o Rationale: The liver's inability to produce adequate albumin decreases oncotic pressure,
allowing fluid to leak into interstitial spaces.
12. A client with pancreatitis complains of severe epigastric pain, so the nurse administers a
prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning
forward. Which intervention should the nurse implement?
o B) Position bedside table so the client can lean across it
Answers
Medical-Surgical Nursing (1-30)
1. A client with heart failure is prescribed furosemide (Lasix). Which laboratory value should the
nurse monitor most closely?
o A) Potassium 3.0 mEq/L
o Rationale: Furosemide is a loop diuretic that causes potassium wasting. Hypokalemia
(potassium < 3.5 mEq/L) can precipitate cardiac dysrhythmias.
2. A client who had a total hip replacement 2 days ago reports sudden shortness of breath and
chest pain. What is the nurse's priority action?
o C) Call the rapid response team
o Rationale: Sudden shortness of breath and chest pain in a post-operative orthopedic
patient are classic signs of a pulmonary embolism (PE), a life-threatening emergency.
3. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 4 L/min via
nasal cannula. The nurse notes the client appears drowsy and has a respiratory rate of 8
breaths per minute. What is the nurse's priority action?
o B) Decrease the oxygen flow rate
o Rationale: The client is exhibiting signs of oxygen-induced hypercapnic respiratory
failure (CO2 narcosis).
4. A client with cirrhosis develops ascites. Which dietary modification is most appropriate?
o B) Restrict sodium intake to 2 g per day
o Rationale: Ascites in cirrhosis is caused by portal hypertension and sodium retention.
Sodium restriction is the first-line dietary intervention.
5. A client receiving chemotherapy develops stomatitis. Which intervention should the nurse
include in the plan of care?
o C) Recommend a soft-bristled toothbrush for oral hygiene
o Rationale: A soft-bristled toothbrush minimizes trauma to the inflamed oral mucosa.
, 6. Four hours following surgical repair of a compound fracture of the right ulna, the nurse is
unable to palpate the client's right radial pulse. Which action should the nurse take first?
o Elevate the client's right hand on one or two pillows
o Rationale: This helps reduce swelling that may be compressing the artery.
7. The nurse is reviewing the laboratory values for a client with acute pancreatitis who reports the
abdominal pain is not as severe as it was on admission. Which laboratory test should the nurse
review to evaluate the client's clinical recovery?
o Lipase
o Rationale: Lipase is more specific to the pancreas and remains elevated longer than
amylase, making it a better indicator of pancreatic inflammation.
8. While assessing a client who had a laparotomy the previous day, the nurse notices that 300 mL
of dark red fluid has drained from the nasogastric tube in the last hour. Which action should
the nurse take first?
o Take vital signs
o Rationale: Dark red drainage indicates active bleeding requiring immediate assessment
of hemodynamic status.
9. A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating Kussmaul breathing
and has a severe headache along with nausea. Her arterial blood gases (ABG) are: pH 7.50;
PaCO2 30 mmHg; HCO3 24 mEq/L. Which assessment finding warrants immediate intervention
by the nurse?
o Fruity breath
o Rationale: Fruity breath indicates ketone production, requiring immediate intervention.
10. As part of the treatment plan for a client diagnosed with acute pancreatitis, the nurse plans to
withhold oral fluids based on which pathophysiological process?
o Decreasing the formation and secretion of pancreatic enzymes
o Rationale: Resting the pancreas by withholding oral fluids and providing IV fluids
decreases pancreatic enzyme secretion.
11. The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and
massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?
o Hypoalbuminemia that results in a decreased colloidal oncotic pressure
o Rationale: The liver's inability to produce adequate albumin decreases oncotic pressure,
allowing fluid to leak into interstitial spaces.
12. A client with pancreatitis complains of severe epigastric pain, so the nurse administers a
prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning
forward. Which intervention should the nurse implement?
o B) Position bedside table so the client can lean across it
