Page 1 of 31
HESI EXIT CAT EXAM 1 2025 WITH VERIFIED
ANSWERS
Following a precipitous labor, a client has a continuous trickling of
bright red blood from her vagina. Her uterus is firm and her vital
signs are within normal limits. The
nurse determines that the client's symptoms may indicate which
condition?
A cervical laceration
In preparing assignments for the shift, which client is best for the
charge nurse to assign to a practical nurse?
An elderly client with Alzheimer's disease complicated by dysphagia
A client is comatose upon arrival to the emergency department after
falling a roof. The client flexes with painful stimuli, and the nurse
determines the client's Glasgow Coma Scale (GCS) is 6. Which
intervention should the nurse prepare to implement to maintain the
client's airway?
A nasopharyngeal tube
A client is receiving a continuous half strength tube feeding at 50
ml/hr. To prepare enough of the solution for eight hours, how many
ml of full strength feeding will the nurse need?
Answer: 200
25 ml x 8hrs = 200
, Page 2 of 31
The alarm of a client's pulse oximeter sounds and the nurse notes
that the oxygen saturation rate is indicated at 85%. What action
should the nurse take first?
Check the probe position
A client is known to have an irregular respiratory rate with periods
of apnea lasting 10 to 15 seconds. Currently, the nurse counts 22
respiratory cycles in a 30-second interval followed by an apneic
period. What intervention should the nurse implement?
Reassess the respiratory rate, counting for one full minute
A retiree with depression complains of feeling "lonely and having no
purpose" in life.Based on Erikson's developmental theory, which
questions suggest that the nurse understands the client's most
important emotional need?
"What about your life makes you proud?"
The healthcare provider prescribes oxygen per nasal cannula at 2
L/min. Which action has the highest priority when the nurse
implements this prescription?
Set the flow meter
9. A nurse who is new to the pediatric unit is positioning a 6-month-
old for an injection of penicillin V (Pen V) in the dorsogluteal muscle.
Which action should the nurse-manager who is supervising this
nurse take first?
C. Instruct the nurse to select another injection site
10. After diagnosis and initial treatment of a 3-year-old child with
cystic fibrosis, the nurse provides home care instructions to the
mother. Which statement by the child's mother indicates that she
understands home care treatment to promote pulmonary function?
, Page 3 of 31
"Chest physiotherapy should be performed at least twice a day"
The nurse is preparing a community education program on
osteoporosis. Which instruction is helpful in preventing bone loss
and promoting bone formation?
Encourage physical activity
The nurse reviews the signs of hypoglycemia with the parents of a
child with Type 1 diabetes mellitus. The parents correctly
understands signs of hypoglycemia if they include which symptom?
Sweating
The nurse observes a 2 cm area nonblanchable erythema on the
sacrum of an immobile client. What documentation of this finding is
best for the nurse to enter into the client's record?
Stage 1 pressure ulcer on sacrum
When assessing a 7-year-old girl, the nurse notes that she has
multiple bruises on her back and upper arms. The child's aunt tells
the nurse that the child's parents abuse drugs and alcohol. What
intervention is most essential for the nurse to implement?
Report assessment findings to the proper legal authorities
15. A 14-year-old male client arrives at the emergency room in
status epilepticus. He was diagnosed with a seizure disorder in
childhood. What is the most likely cause of his present condition?
Acute withdrawal from anticonvulsant medication
A Chinese-American client who just delivered a baby states that she
will not be able to take the prescribed sitz baths to help heal her
episiotomy incision because this will cause an unhealthy balance of
, Page 4 of 31
cold and hot forces. When planning nursing care, what nursing
diagnosis has the highest priority?
Impaired tissue integrity related to episiotomy
17. A 2-year-old with sickle cell anemia has an axillary temperature
of 102 F. In planning care for this child, which nursing diagnosis has
the highest priority?
High risk for fluid volume deficit related to temperature elevation
During the first trimester of pregnancy, a client who was treated for
genital herpes with acyclovir (Zovirax) prior to this pregnancy tells
the nurse that she is experiencing an episode of genital herpes.
Which nursing intervention has the highest priority?
Determine if the client has taken acyclovir (Zovirax) for this
outbreak of genital herpes
The nurse is obtaining a medication history for a client with a new
prescription for paroxetine (Paxil). The client reports current use of
the MAO inhibitor isocarboxazid
(Marplan). What intervention is most important for the nurse to
implement?
Notify the healthcare provider that the client is currently taking
Marplan
While performing a skin inspection on a newborn, the nurse finds a
small dimple and a dark tuft of hair in the lumbosacral area of the
infant's back. What is the most likely indication of this finding?
External manifestation of a spinal abnormality
What action should the nurse implement first when delegating
nursing activities to an unlicensed assistive personnel (UAP)?
HESI EXIT CAT EXAM 1 2025 WITH VERIFIED
ANSWERS
Following a precipitous labor, a client has a continuous trickling of
bright red blood from her vagina. Her uterus is firm and her vital
signs are within normal limits. The
nurse determines that the client's symptoms may indicate which
condition?
A cervical laceration
In preparing assignments for the shift, which client is best for the
charge nurse to assign to a practical nurse?
An elderly client with Alzheimer's disease complicated by dysphagia
A client is comatose upon arrival to the emergency department after
falling a roof. The client flexes with painful stimuli, and the nurse
determines the client's Glasgow Coma Scale (GCS) is 6. Which
intervention should the nurse prepare to implement to maintain the
client's airway?
A nasopharyngeal tube
A client is receiving a continuous half strength tube feeding at 50
ml/hr. To prepare enough of the solution for eight hours, how many
ml of full strength feeding will the nurse need?
Answer: 200
25 ml x 8hrs = 200
, Page 2 of 31
The alarm of a client's pulse oximeter sounds and the nurse notes
that the oxygen saturation rate is indicated at 85%. What action
should the nurse take first?
Check the probe position
A client is known to have an irregular respiratory rate with periods
of apnea lasting 10 to 15 seconds. Currently, the nurse counts 22
respiratory cycles in a 30-second interval followed by an apneic
period. What intervention should the nurse implement?
Reassess the respiratory rate, counting for one full minute
A retiree with depression complains of feeling "lonely and having no
purpose" in life.Based on Erikson's developmental theory, which
questions suggest that the nurse understands the client's most
important emotional need?
"What about your life makes you proud?"
The healthcare provider prescribes oxygen per nasal cannula at 2
L/min. Which action has the highest priority when the nurse
implements this prescription?
Set the flow meter
9. A nurse who is new to the pediatric unit is positioning a 6-month-
old for an injection of penicillin V (Pen V) in the dorsogluteal muscle.
Which action should the nurse-manager who is supervising this
nurse take first?
C. Instruct the nurse to select another injection site
10. After diagnosis and initial treatment of a 3-year-old child with
cystic fibrosis, the nurse provides home care instructions to the
mother. Which statement by the child's mother indicates that she
understands home care treatment to promote pulmonary function?
, Page 3 of 31
"Chest physiotherapy should be performed at least twice a day"
The nurse is preparing a community education program on
osteoporosis. Which instruction is helpful in preventing bone loss
and promoting bone formation?
Encourage physical activity
The nurse reviews the signs of hypoglycemia with the parents of a
child with Type 1 diabetes mellitus. The parents correctly
understands signs of hypoglycemia if they include which symptom?
Sweating
The nurse observes a 2 cm area nonblanchable erythema on the
sacrum of an immobile client. What documentation of this finding is
best for the nurse to enter into the client's record?
Stage 1 pressure ulcer on sacrum
When assessing a 7-year-old girl, the nurse notes that she has
multiple bruises on her back and upper arms. The child's aunt tells
the nurse that the child's parents abuse drugs and alcohol. What
intervention is most essential for the nurse to implement?
Report assessment findings to the proper legal authorities
15. A 14-year-old male client arrives at the emergency room in
status epilepticus. He was diagnosed with a seizure disorder in
childhood. What is the most likely cause of his present condition?
Acute withdrawal from anticonvulsant medication
A Chinese-American client who just delivered a baby states that she
will not be able to take the prescribed sitz baths to help heal her
episiotomy incision because this will cause an unhealthy balance of
, Page 4 of 31
cold and hot forces. When planning nursing care, what nursing
diagnosis has the highest priority?
Impaired tissue integrity related to episiotomy
17. A 2-year-old with sickle cell anemia has an axillary temperature
of 102 F. In planning care for this child, which nursing diagnosis has
the highest priority?
High risk for fluid volume deficit related to temperature elevation
During the first trimester of pregnancy, a client who was treated for
genital herpes with acyclovir (Zovirax) prior to this pregnancy tells
the nurse that she is experiencing an episode of genital herpes.
Which nursing intervention has the highest priority?
Determine if the client has taken acyclovir (Zovirax) for this
outbreak of genital herpes
The nurse is obtaining a medication history for a client with a new
prescription for paroxetine (Paxil). The client reports current use of
the MAO inhibitor isocarboxazid
(Marplan). What intervention is most important for the nurse to
implement?
Notify the healthcare provider that the client is currently taking
Marplan
While performing a skin inspection on a newborn, the nurse finds a
small dimple and a dark tuft of hair in the lumbosacral area of the
infant's back. What is the most likely indication of this finding?
External manifestation of a spinal abnormality
What action should the nurse implement first when delegating
nursing activities to an unlicensed assistive personnel (UAP)?
