EXIT HESI Comprehensive Practice
Questions and multiple choice answers
2025 |ready to pass
A client is admitted to the hospital with the diagnosis of hypokalemia.
Which clinical manifestation is most significant?
A.Heart palpitations
B.Leg cramps
C.Nausea
D.Tetany - answ✔✔A
Rationale:
Hypokalemia can cause heart palpitations, which are indicative of a
dysrhythmia that could progress to a medical emergency (A). (B and C)
are also of concern but are not as life threatening. (D) is a symptom of
hypocalcemia.
A nurse working in the emergency department admits a client with full-
thickness burns to 50% of the body. Assessment findings indicate high-
pitched wheezing, heart rate of 120 beats/min, and disorientation.
Which action should the nurse take first?
A.Insert a large-bore IV for fluid resuscitation.
B.Prepare to assist with maintaining the airway.
C.Cleanse the wounds using sterile technique.
D.Administer an analgesic for pain. - answ✔✔B
,Rationale:
High-pitched wheezing indicates laryngeal stridor, a sign of laryngeal
edema associated with lung injury. Airway management is the first
priority of care (B). (A, C, and D) are all appropriate interventions in
managing the client with a burn but are not as critical as establishing an
airway.
The nurse prepares to administer digoxin (Lanoxin), 0.125 mg PO, to an
adult client with heart failure and notes that the digoxin serum level in
the laboratory report is 1 ng/mL. Which action should the nurse take?
A.Discontinue the digoxin.
B.Notify health care provider.
C.Administer the digoxin.
D.Reverify the digoxin level. - answ✔✔C
Rationale:
A therapeutic range for digoxin is 0.5 to 2 ng/mL (C). The digoxin should
be continued to maintain a therapeutic range (C). The others actions
are not indicated for a therapeutic range (A, B, and D).
The nurse is assessing a client at 20 weeks' gestation. Which
measurement should be compared with the client's current weight to
obtain the most accurate data about her weight gain during pregnancy?
A.Usual prepregnant weight
B.Weight at the first prenatal visit
C.Weight during previous pregnancy
,D.Recommended pattern of weight gain - answ✔✔A
Rationale:
Comparing the client's current weight with her prepregnant weight (A)
allows for the calculation of weight gain. By the time of the first
prenatal visit (B), she may have already gained weight. (C) may not be
relevant to weight gain with the current pregnancy. (D) should be
evaluated based on serial weights, not just a single current weight.
The nurse is caring for a client with a cerebrovascular accident (CVA)
who is receiving enteral tube feedings. Which task performed by the
UAP requires immediate intervention by the nurse?
A.Suctions oral secretions from mouth
B.Positions head of bed flat when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of bed elevated at 30 degrees - answ✔✔B
Rationale:
Positioning the head of the bed flat when enteral feedings are in
progress puts the client at risk for aspiration (B). The others are all
acceptable tasks performed by the UAP (A, C, and D).
When caring for a postsurgical client who has undergone multiple
blood transfusions, which serum laboratory finding is of most concern
to the nurse?
A.Sodium level, 137 mEq/L
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
, D.Calcium level, 10 mEq/L - answ✔✔B
Rationale:
Multiple blood transfusions are a risk factor for hyperkalemia. A serum
potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The
others are normal findings (A, C, and D).
Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine - answ✔✔A
Rationale:
The hepatitis B vaccination should be given to all newborns before
hospital discharge (A). HPV is not recommended until adolescence (B).
Varicella immunization begins at 12 months (C). Meningococcal vaccine
is administered beginning at 2 years (D).
The nurse is caring for a client on the medical unit. Which task can be
delegated to unlicensed assistive personnel (UAP)?
A.Assess the need to change a central line dressing.
B.Obtain a fingerstick blood glucose level.
C.Answer a family member's questions about the client's plan of care.
D.Teach the client side effects to report related to the current
medication regimen. - answ✔✔B
Questions and multiple choice answers
2025 |ready to pass
A client is admitted to the hospital with the diagnosis of hypokalemia.
Which clinical manifestation is most significant?
A.Heart palpitations
B.Leg cramps
C.Nausea
D.Tetany - answ✔✔A
Rationale:
Hypokalemia can cause heart palpitations, which are indicative of a
dysrhythmia that could progress to a medical emergency (A). (B and C)
are also of concern but are not as life threatening. (D) is a symptom of
hypocalcemia.
A nurse working in the emergency department admits a client with full-
thickness burns to 50% of the body. Assessment findings indicate high-
pitched wheezing, heart rate of 120 beats/min, and disorientation.
Which action should the nurse take first?
A.Insert a large-bore IV for fluid resuscitation.
B.Prepare to assist with maintaining the airway.
C.Cleanse the wounds using sterile technique.
D.Administer an analgesic for pain. - answ✔✔B
,Rationale:
High-pitched wheezing indicates laryngeal stridor, a sign of laryngeal
edema associated with lung injury. Airway management is the first
priority of care (B). (A, C, and D) are all appropriate interventions in
managing the client with a burn but are not as critical as establishing an
airway.
The nurse prepares to administer digoxin (Lanoxin), 0.125 mg PO, to an
adult client with heart failure and notes that the digoxin serum level in
the laboratory report is 1 ng/mL. Which action should the nurse take?
A.Discontinue the digoxin.
B.Notify health care provider.
C.Administer the digoxin.
D.Reverify the digoxin level. - answ✔✔C
Rationale:
A therapeutic range for digoxin is 0.5 to 2 ng/mL (C). The digoxin should
be continued to maintain a therapeutic range (C). The others actions
are not indicated for a therapeutic range (A, B, and D).
The nurse is assessing a client at 20 weeks' gestation. Which
measurement should be compared with the client's current weight to
obtain the most accurate data about her weight gain during pregnancy?
A.Usual prepregnant weight
B.Weight at the first prenatal visit
C.Weight during previous pregnancy
,D.Recommended pattern of weight gain - answ✔✔A
Rationale:
Comparing the client's current weight with her prepregnant weight (A)
allows for the calculation of weight gain. By the time of the first
prenatal visit (B), she may have already gained weight. (C) may not be
relevant to weight gain with the current pregnancy. (D) should be
evaluated based on serial weights, not just a single current weight.
The nurse is caring for a client with a cerebrovascular accident (CVA)
who is receiving enteral tube feedings. Which task performed by the
UAP requires immediate intervention by the nurse?
A.Suctions oral secretions from mouth
B.Positions head of bed flat when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of bed elevated at 30 degrees - answ✔✔B
Rationale:
Positioning the head of the bed flat when enteral feedings are in
progress puts the client at risk for aspiration (B). The others are all
acceptable tasks performed by the UAP (A, C, and D).
When caring for a postsurgical client who has undergone multiple
blood transfusions, which serum laboratory finding is of most concern
to the nurse?
A.Sodium level, 137 mEq/L
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
, D.Calcium level, 10 mEq/L - answ✔✔B
Rationale:
Multiple blood transfusions are a risk factor for hyperkalemia. A serum
potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The
others are normal findings (A, C, and D).
Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine - answ✔✔A
Rationale:
The hepatitis B vaccination should be given to all newborns before
hospital discharge (A). HPV is not recommended until adolescence (B).
Varicella immunization begins at 12 months (C). Meningococcal vaccine
is administered beginning at 2 years (D).
The nurse is caring for a client on the medical unit. Which task can be
delegated to unlicensed assistive personnel (UAP)?
A.Assess the need to change a central line dressing.
B.Obtain a fingerstick blood glucose level.
C.Answer a family member's questions about the client's plan of care.
D.Teach the client side effects to report related to the current
medication regimen. - answ✔✔B
