HESI RN EXIT EXAM V5 – 130
Questions and Verified Answers
Detailed Rationales | Latest Update
Question 1
After placing a 30-second gestation position in an icecube and drying the infant
with several blankets, what should the nurse implement next?
A) Administer the vitamin K injection
B) Remove the wet blankets and linens from the isolette
C) Place erythromycin ophthalmic ointment in both eyes
D) Open the isolette door to assess the infant's vital signs
Answer: B
Rationale: After drying the newborn, wet blankets should be removed to prevent
hypothermia. Wet linens increase heat loss by evaporation. Vitamin K and eye
ointment can be given after the infant is stable and warm. Opening the isolette
door loses heat.
Question 2
A client with heart failure is receiving furosemide (Lasix) 40 mg IV. Which
assessment finding indicates the medication is effective?
A) Urine output 200 mL in the past 2 hours
B) Blood pressure 90/60 mmHg
C) Respiratory rate 28 breaths/min
D) Weight gain of 1 kg in 24 hours
Answer: A
Rationale: Furosemide is a loop diuretic; effectiveness is measured by increased
urine output, reduced edema, and weight loss. Hypotension and tachypnea are not
desired outcomes. Weight gain indicates fluid retention.
,Question 3
A client with type 1 diabetes mellitus is found unconscious. A blood glucose
reading is unavailable. What should the nurse do first?
A) Administer 50% dextrose IV push
B) Give glucagon subcutaneously
C) Provide orange juice orally
D) Wait for the lab result
Answer: A
Rationale: Unconscious diabetic – assume hypoglycemia. IV dextrose is fastest.
Glucagon is used if no IV access. Oral fluids are unsafe. Do not delay treatment.
Question 4
The nurse is caring for a client with a chest tube following a thoracotomy. Which
finding requires immediate intervention?
A) Continuous bubbling in the water seal chamber
B) Tidaling in the water seal chamber
C) 100 mL of serosanguineous drainage in the first 8 hours
D) Subcutaneous emphysema around the insertion site
Answer: A
Rationale: Continuous bubbling indicates an air leak. Tidaling is normal. Mild
drainage and small subcutaneous emphysema are expected.
Question 5
A client with major depressive disorder is started on phenelzine (MAOI). Which
food should the nurse instruct the client to avoid?
A) Aged cheese
B) Apples
C) Rice
D) Chicken
, Answer: A
Rationale: MAOIs interact with tyramine-rich foods (aged cheese, cured meats,
fermented products) causing hypertensive crisis.
Question 6
The nurse assesses a newborn’s Apgar score at 1 minute. Which finding would
assign a score of 1 for heart rate?
A) Heart rate 90 beats/min
B) Heart rate 0
C) Heart rate 140 beats/min
D) Heart rate irregular
Answer: A
*Rationale: Apgar heart rate scoring: 0 = absent, 1 = <100 bpm, 2 = ≥100 bpm. 90
bpm scores 1.*
Question 7
A client with chronic kidney disease (CKD) has a serum potassium of 6.2 mEq/L.
Which medication should the nurse prepare to administer?
A) Calcium gluconate
B) Potassium chloride
C) Spironolactone
D) Furosemide
Answer: A
*Rationale: Hyperkalemia (K >5.5) requires cardiac stabilization first with IV
calcium gluconate. Then insulin/glucose, albuterol, or kayexalate.*
Question 8
The nurse is teaching a client with a new colostomy. Which statement indicates
correct understanding?
Questions and Verified Answers
Detailed Rationales | Latest Update
Question 1
After placing a 30-second gestation position in an icecube and drying the infant
with several blankets, what should the nurse implement next?
A) Administer the vitamin K injection
B) Remove the wet blankets and linens from the isolette
C) Place erythromycin ophthalmic ointment in both eyes
D) Open the isolette door to assess the infant's vital signs
Answer: B
Rationale: After drying the newborn, wet blankets should be removed to prevent
hypothermia. Wet linens increase heat loss by evaporation. Vitamin K and eye
ointment can be given after the infant is stable and warm. Opening the isolette
door loses heat.
Question 2
A client with heart failure is receiving furosemide (Lasix) 40 mg IV. Which
assessment finding indicates the medication is effective?
A) Urine output 200 mL in the past 2 hours
B) Blood pressure 90/60 mmHg
C) Respiratory rate 28 breaths/min
D) Weight gain of 1 kg in 24 hours
Answer: A
Rationale: Furosemide is a loop diuretic; effectiveness is measured by increased
urine output, reduced edema, and weight loss. Hypotension and tachypnea are not
desired outcomes. Weight gain indicates fluid retention.
,Question 3
A client with type 1 diabetes mellitus is found unconscious. A blood glucose
reading is unavailable. What should the nurse do first?
A) Administer 50% dextrose IV push
B) Give glucagon subcutaneously
C) Provide orange juice orally
D) Wait for the lab result
Answer: A
Rationale: Unconscious diabetic – assume hypoglycemia. IV dextrose is fastest.
Glucagon is used if no IV access. Oral fluids are unsafe. Do not delay treatment.
Question 4
The nurse is caring for a client with a chest tube following a thoracotomy. Which
finding requires immediate intervention?
A) Continuous bubbling in the water seal chamber
B) Tidaling in the water seal chamber
C) 100 mL of serosanguineous drainage in the first 8 hours
D) Subcutaneous emphysema around the insertion site
Answer: A
Rationale: Continuous bubbling indicates an air leak. Tidaling is normal. Mild
drainage and small subcutaneous emphysema are expected.
Question 5
A client with major depressive disorder is started on phenelzine (MAOI). Which
food should the nurse instruct the client to avoid?
A) Aged cheese
B) Apples
C) Rice
D) Chicken
, Answer: A
Rationale: MAOIs interact with tyramine-rich foods (aged cheese, cured meats,
fermented products) causing hypertensive crisis.
Question 6
The nurse assesses a newborn’s Apgar score at 1 minute. Which finding would
assign a score of 1 for heart rate?
A) Heart rate 90 beats/min
B) Heart rate 0
C) Heart rate 140 beats/min
D) Heart rate irregular
Answer: A
*Rationale: Apgar heart rate scoring: 0 = absent, 1 = <100 bpm, 2 = ≥100 bpm. 90
bpm scores 1.*
Question 7
A client with chronic kidney disease (CKD) has a serum potassium of 6.2 mEq/L.
Which medication should the nurse prepare to administer?
A) Calcium gluconate
B) Potassium chloride
C) Spironolactone
D) Furosemide
Answer: A
*Rationale: Hyperkalemia (K >5.5) requires cardiac stabilization first with IV
calcium gluconate. Then insulin/glucose, albuterol, or kayexalate.*
Question 8
The nurse is teaching a client with a new colostomy. Which statement indicates
correct understanding?
