HESI VERSION 2 RN EXIT EXAM
WITH NGN RETAKE EXAM WITH
QUESTIONS AND 100% VERIFIED
ANSWERS LATEST UPDATE
2024/2025. NEW!!! NEW!!! NEW!!!
A male client who fell off a roof has right and left femur fractures and crushing
injuries to both ankles. He is supine with bilateral skin traction applied to the
lower extremities while awaiting surgery within the next 4 hours. When asked to
evaluate his pain on a scale of 1 to 10, he screams that it is 20. For the last 4
hours, he has received morphine 2 mg IV hourly. His vital signs are heart rate
130 beats/minute, respirations 32 breaths/minute, blood pressure 180/90
mmHg. Which intervention is most important for the nurse to implement?
A. Request the healthcare provider to consider a different analgesic
B. Evaluate the traction for amount of tension applied to each extremity
C. Determine if client is experiencing cumulative effects of the total dosage
D. Assess the extremities for signs of compartment syndrome q2 hours -
ANS✔✔-D. Assess the extremities for signs of compartment syndrome q2 hours
Well caring for a toddler receiving oxygen via facemask, the nurse observes that
the child's lips and nares are dry and cracked. Which intervention should the
nurse implement?
A. Use a topical lidocaine analgesic for cracked lips
B. Use a water-soluble lubricant on affected oral and nasal mucosa
C. Ask the mother what she usually uses on the child's lips and nose
D. Apply a petroleum jelly to the child's nose - ANS✔✔-B. Use a water-soluble
lubricant on affected oral and nasal mucosa
,The nurse is assessing a client who returns to the unit after a thoracentesis in
the procedure room. Which finding should the nurse report to the healthcare
provider immediately?
A. Diminished breath sounds over the trocar insertion site
B. Equal bilateral chest extension
C. Scattered crackles unchanged from baseline
D. Respiratory rate of 22 breaths/minute - ANS✔✔-A. Diminished breath sounds
over the trocar insertion site
An adult client is admitted to the emergency department after falling from a
ladder. While waiting to have a computer tomography (CT) scan, the client
requests something for a severe headache. When the nurse offers a prescribed
dose of acetaminophen, the client asks for something stronger. Which
intervention should the nurse implement?
A. Assess clients peoples for their reaction to light
B. Request that the CT scan beats immediately
C. Review client's history for use of illicit drugs
D. Explain the reason for using only non-narcotics - ANS✔✔-D. Explain the
reason for using only non-narcotics
When caring for a client with a traumatic brain injury (TBI) who had a
craniotomy for increased intracranial pressure (ICP), the nurse assesses the
client using the Glasgow coma scale (GCS) every two hours. For the past eight
hours the client's GCS score has been 14. What does this GCS finding indicate
about the client?
A. Rehabilitative prognosis is an expected full recovery
B. Risk for a reversible cerebral damage related to increased ICP
C. Insertion of an ICP monitoring device is necessary
D. Neurologically stable without indications of an increased ICP - ANS✔✔-D.
Neurologically stable without indications of an increased ICP
A client with cirrhosis of the liver is admitted with complications related to end-
stage liver disease. Which intervention should the nurse implement? (Select all
that apply)
A. Report serum albumin and globulin levels
, B. Provide diet low in phosphorus
C. Note signs of swelling in edema
D. Monitor abdominal girth
E Increase oral fluid intake to 1500 mL daily - ANS✔✔-A. Report serum albumin
and globulin levels
C. Note signs of swelling in edema
D. Monitor abdominal girth
The nurse is caring for a seated client who is experiencing a tonic-clonic seizure.
Which actions should the nurse implement? (Select all that apply)
A. Insert a bite block
B. Restrain the client
C. Loosen restrictive clothing
D. Note the duration of the seizure
E. Ease the client to the floor - ANS✔✔-C. Loosen restrictive clothing
D. Note the duration of the seizure
E. Ease the client to the floor
The nurse caring for a child with mononucleosis can expect a child to exhibit
which symptoms?
A. Positive Epstein-Barr, and malaise
B. Ear pain and fever
C. Elevated WBC and sedimentation rate
D. Increased BUN and serum creatinine - ANS✔✔-B. Ear pain and fever
The public health nurse receives funding to initiate a primary prevention
program in the community. Which program best fits the nurse's proposal?
A. Regional relocation center for earthquake victims
B. Vitamin supplements for high-risk pregnant women
C. Lead screening for children in low income housing
D. Case management and screening for clients with HIV - ANS✔✔-B. Vitamin
supplements for high-risk pregnant women
WITH NGN RETAKE EXAM WITH
QUESTIONS AND 100% VERIFIED
ANSWERS LATEST UPDATE
2024/2025. NEW!!! NEW!!! NEW!!!
A male client who fell off a roof has right and left femur fractures and crushing
injuries to both ankles. He is supine with bilateral skin traction applied to the
lower extremities while awaiting surgery within the next 4 hours. When asked to
evaluate his pain on a scale of 1 to 10, he screams that it is 20. For the last 4
hours, he has received morphine 2 mg IV hourly. His vital signs are heart rate
130 beats/minute, respirations 32 breaths/minute, blood pressure 180/90
mmHg. Which intervention is most important for the nurse to implement?
A. Request the healthcare provider to consider a different analgesic
B. Evaluate the traction for amount of tension applied to each extremity
C. Determine if client is experiencing cumulative effects of the total dosage
D. Assess the extremities for signs of compartment syndrome q2 hours -
ANS✔✔-D. Assess the extremities for signs of compartment syndrome q2 hours
Well caring for a toddler receiving oxygen via facemask, the nurse observes that
the child's lips and nares are dry and cracked. Which intervention should the
nurse implement?
A. Use a topical lidocaine analgesic for cracked lips
B. Use a water-soluble lubricant on affected oral and nasal mucosa
C. Ask the mother what she usually uses on the child's lips and nose
D. Apply a petroleum jelly to the child's nose - ANS✔✔-B. Use a water-soluble
lubricant on affected oral and nasal mucosa
,The nurse is assessing a client who returns to the unit after a thoracentesis in
the procedure room. Which finding should the nurse report to the healthcare
provider immediately?
A. Diminished breath sounds over the trocar insertion site
B. Equal bilateral chest extension
C. Scattered crackles unchanged from baseline
D. Respiratory rate of 22 breaths/minute - ANS✔✔-A. Diminished breath sounds
over the trocar insertion site
An adult client is admitted to the emergency department after falling from a
ladder. While waiting to have a computer tomography (CT) scan, the client
requests something for a severe headache. When the nurse offers a prescribed
dose of acetaminophen, the client asks for something stronger. Which
intervention should the nurse implement?
A. Assess clients peoples for their reaction to light
B. Request that the CT scan beats immediately
C. Review client's history for use of illicit drugs
D. Explain the reason for using only non-narcotics - ANS✔✔-D. Explain the
reason for using only non-narcotics
When caring for a client with a traumatic brain injury (TBI) who had a
craniotomy for increased intracranial pressure (ICP), the nurse assesses the
client using the Glasgow coma scale (GCS) every two hours. For the past eight
hours the client's GCS score has been 14. What does this GCS finding indicate
about the client?
A. Rehabilitative prognosis is an expected full recovery
B. Risk for a reversible cerebral damage related to increased ICP
C. Insertion of an ICP monitoring device is necessary
D. Neurologically stable without indications of an increased ICP - ANS✔✔-D.
Neurologically stable without indications of an increased ICP
A client with cirrhosis of the liver is admitted with complications related to end-
stage liver disease. Which intervention should the nurse implement? (Select all
that apply)
A. Report serum albumin and globulin levels
, B. Provide diet low in phosphorus
C. Note signs of swelling in edema
D. Monitor abdominal girth
E Increase oral fluid intake to 1500 mL daily - ANS✔✔-A. Report serum albumin
and globulin levels
C. Note signs of swelling in edema
D. Monitor abdominal girth
The nurse is caring for a seated client who is experiencing a tonic-clonic seizure.
Which actions should the nurse implement? (Select all that apply)
A. Insert a bite block
B. Restrain the client
C. Loosen restrictive clothing
D. Note the duration of the seizure
E. Ease the client to the floor - ANS✔✔-C. Loosen restrictive clothing
D. Note the duration of the seizure
E. Ease the client to the floor
The nurse caring for a child with mononucleosis can expect a child to exhibit
which symptoms?
A. Positive Epstein-Barr, and malaise
B. Ear pain and fever
C. Elevated WBC and sedimentation rate
D. Increased BUN and serum creatinine - ANS✔✔-B. Ear pain and fever
The public health nurse receives funding to initiate a primary prevention
program in the community. Which program best fits the nurse's proposal?
A. Regional relocation center for earthquake victims
B. Vitamin supplements for high-risk pregnant women
C. Lead screening for children in low income housing
D. Case management and screening for clients with HIV - ANS✔✔-B. Vitamin
supplements for high-risk pregnant women
