HESI EXIT V2 NURSING CLINICAL SCENARIOS EXAM 2025,
181 QUESTIONS WITH ACCURATE SOLUTIONS
What is the primary physiological issue in premature infants with respiratory
distress syndrome that affects their ability to breathe properly?
Inability to stabilize thermoregulation
Inadequate maintenance of alveolar surface tension
Failure to initiate normal pulmonary blood flow
Difficulty in regulating intracardiac pressure
1. Why is it important for the nurse to reassess the child's temperature
after the mother reports that the child feels warm?
To confirm the mother's observation and determine if there is a
fever
To distract the child from discomfort after surgery
To prepare for potential medication administration
To document the mother's concerns in the medical record
2. A client with anorexia is hospitalized on a medical unit due to
electrolyte imbalance and cardiac dysrhythmias. Additional assessment
findings that the nurse would expect to observe are
Brittle hair, lanugo, amenorrhea
Diarrhea, nausea, vomiting, dental erosion
Hyperthermia, tachycardia, increased metabolic rate
Excessive anxiety about symptoms
3. A nurse is caring for a client who was successfully resuscitated from a
pulseless arrhythmia. Which assessment is critical for the nurse to
include in the plan of care?
Blood glucose every four hours
, Temperature every two hours
Hourly urine output
White blood count trends
4. The nurse manager called a meeting with one of the unit team
leaders because clients have complained that they are not receiving
their
medication on time. the nurse manager should include which of the
following good time management strategies during the meeting with the
unit team leader?
the nurse manager wants all team leaders to take the first hour of
each shift to set client care priorities
the nurse manager realizes that time management strategies are
unrealistic when staffing is too low
all team leaders must look at the overall work to be done and
set appropriate priorities
optimal outcomes can only be achieved by implementing essential
physical tasks
5. The psychiatric-mental health nurse understands the goal of milieu
therapy is which of the following?
To structure the environment to ensure a therapeutic experience
To encourage clients to be active participants in their therapy
To provide spontaneous opportunities for therapeutic interactions
To design a homelike atmosphere that encourages communication
6. What is the most effective treatment for promoting healing in a Stage 2
skin ulcer?
Covering the wound with a dry dressing
Using hydrogen peroxide soaks
Leaving the area open to dry
, Applying a hydrocolloid or foam dressing
7. Which of the following tasks is appropriate for an unlicensed
assistive personnel (UAP) to perform in a clinical setting?
A) Administer medications to a patient
B) Assist a patient with activities of daily living
C) Conduct a physical assessment of a patient
D) Develop a nursing care plan for a patient
8. Why might the assignment of managing an admission with atrial
fibrillation and heart failure at shift change be questioned by the nurse
manager?
The patient requires immediate assessment and stabilization.
The PN nursing student lacks experience with admissions.
The UAP is not trained to handle complex medical conditions.
The charge nurse is responsible for all admissions.
9. A nursing team is tasked with redesigning the inpatient milieu for
a psychiatric unit. Which strategy should they prioritize to
enhance
therapeutic outcomes for clients?
A) Implementing strict rules that limit client interactions to
reduce conflict
B) Creating opportunities for clients to collaboratively establish
unit guidelines and engage in group activities
C) Focusing solely on individual therapy sessions without group
involvement
D) Enforcing a zero-tolerance policy for emotional expressions to
maintain order
10. The nurse in the well-child clinic received a phone call from the parent of
the 6-month-old who received the DTaP vaccine 3 days ago. The nurse is
, most concerned if the parent makes which statement?
"There is redness and swelling at the injection site"
"My baby is crying continuously"
"My baby's temperature is 101F (38.3C)"
"My baby seems to be eating less"
11. A patient who is experiencing an acute asthma attack is admitted to
the emergency department. Which assessment should the nurse
complete first?
Listen to the patient's breath sounds
Ask about inhaled corticosteroid
use Determine when the dyspnea
started
Obtain the forced expiratory volume (FEV) flow rate
12. A nurse is preparing a client diagnosed with a deep vein thrombosis
(DVT) for a venous doppler evaluation. Which nursing intervention is
necessary to prepare the client for this test?
Discontinue anticoagulant therapy just before to the
test Have ready a sedative medication prior to the
test
Keep the client NPO after midnight
No special preparation is necessary for the client
13. A client who is to undergo a mastectomy for breast cancer says, "I am
worried about what I'll look like after surgery." Which response would
the nurse use?
"I understand that you'd be concerned about appearance."
"Try not to think about the surgery or the outcomes."
"Anyone in your position would feel the same way."
181 QUESTIONS WITH ACCURATE SOLUTIONS
What is the primary physiological issue in premature infants with respiratory
distress syndrome that affects their ability to breathe properly?
Inability to stabilize thermoregulation
Inadequate maintenance of alveolar surface tension
Failure to initiate normal pulmonary blood flow
Difficulty in regulating intracardiac pressure
1. Why is it important for the nurse to reassess the child's temperature
after the mother reports that the child feels warm?
To confirm the mother's observation and determine if there is a
fever
To distract the child from discomfort after surgery
To prepare for potential medication administration
To document the mother's concerns in the medical record
2. A client with anorexia is hospitalized on a medical unit due to
electrolyte imbalance and cardiac dysrhythmias. Additional assessment
findings that the nurse would expect to observe are
Brittle hair, lanugo, amenorrhea
Diarrhea, nausea, vomiting, dental erosion
Hyperthermia, tachycardia, increased metabolic rate
Excessive anxiety about symptoms
3. A nurse is caring for a client who was successfully resuscitated from a
pulseless arrhythmia. Which assessment is critical for the nurse to
include in the plan of care?
Blood glucose every four hours
, Temperature every two hours
Hourly urine output
White blood count trends
4. The nurse manager called a meeting with one of the unit team
leaders because clients have complained that they are not receiving
their
medication on time. the nurse manager should include which of the
following good time management strategies during the meeting with the
unit team leader?
the nurse manager wants all team leaders to take the first hour of
each shift to set client care priorities
the nurse manager realizes that time management strategies are
unrealistic when staffing is too low
all team leaders must look at the overall work to be done and
set appropriate priorities
optimal outcomes can only be achieved by implementing essential
physical tasks
5. The psychiatric-mental health nurse understands the goal of milieu
therapy is which of the following?
To structure the environment to ensure a therapeutic experience
To encourage clients to be active participants in their therapy
To provide spontaneous opportunities for therapeutic interactions
To design a homelike atmosphere that encourages communication
6. What is the most effective treatment for promoting healing in a Stage 2
skin ulcer?
Covering the wound with a dry dressing
Using hydrogen peroxide soaks
Leaving the area open to dry
, Applying a hydrocolloid or foam dressing
7. Which of the following tasks is appropriate for an unlicensed
assistive personnel (UAP) to perform in a clinical setting?
A) Administer medications to a patient
B) Assist a patient with activities of daily living
C) Conduct a physical assessment of a patient
D) Develop a nursing care plan for a patient
8. Why might the assignment of managing an admission with atrial
fibrillation and heart failure at shift change be questioned by the nurse
manager?
The patient requires immediate assessment and stabilization.
The PN nursing student lacks experience with admissions.
The UAP is not trained to handle complex medical conditions.
The charge nurse is responsible for all admissions.
9. A nursing team is tasked with redesigning the inpatient milieu for
a psychiatric unit. Which strategy should they prioritize to
enhance
therapeutic outcomes for clients?
A) Implementing strict rules that limit client interactions to
reduce conflict
B) Creating opportunities for clients to collaboratively establish
unit guidelines and engage in group activities
C) Focusing solely on individual therapy sessions without group
involvement
D) Enforcing a zero-tolerance policy for emotional expressions to
maintain order
10. The nurse in the well-child clinic received a phone call from the parent of
the 6-month-old who received the DTaP vaccine 3 days ago. The nurse is
, most concerned if the parent makes which statement?
"There is redness and swelling at the injection site"
"My baby is crying continuously"
"My baby's temperature is 101F (38.3C)"
"My baby seems to be eating less"
11. A patient who is experiencing an acute asthma attack is admitted to
the emergency department. Which assessment should the nurse
complete first?
Listen to the patient's breath sounds
Ask about inhaled corticosteroid
use Determine when the dyspnea
started
Obtain the forced expiratory volume (FEV) flow rate
12. A nurse is preparing a client diagnosed with a deep vein thrombosis
(DVT) for a venous doppler evaluation. Which nursing intervention is
necessary to prepare the client for this test?
Discontinue anticoagulant therapy just before to the
test Have ready a sedative medication prior to the
test
Keep the client NPO after midnight
No special preparation is necessary for the client
13. A client who is to undergo a mastectomy for breast cancer says, "I am
worried about what I'll look like after surgery." Which response would
the nurse use?
"I understand that you'd be concerned about appearance."
"Try not to think about the surgery or the outcomes."
"Anyone in your position would feel the same way."
