NIGHTINGALE HESI EXIT 2 (2025) QUESTIONS WITH
COMPLETE SOLUTIONS
A 12-year-old client who had an appendectomy two days ago is
receiving 0.9% normal saline at 50mL/hr. The client's urine
specific gravity is 1.035. Which action should the nurse
implement?
A. Assess bowel sounds in all quadrants
B. Encourage popsicles and fluids of choice
C. Evaluate postural blood pressure measurements
D. Obtain a specimen for urinalysis Correct Answers B.
Encourage popsicles and fluids of choice
A 3-year-old boy was successfully toilet trained prior to his
admission to the hospital for injuries sustained from a fall. His
parents are very concerned that the child has regressed in his
toileting behaviors. Which information should the nurse provide
to the parents?
A. Diapering will be provided since hospitalization is stressful to
preschoolers
B. Children usually resume their toileting behaviors when they
leave the hospital
C. A potty chair should be brought from home so he can
maintain his toileting skills
D. A retraining program will need to be initiated when the child
returns home Correct Answers B. Children usually resume
their toileting behaviors when they leave the hospital
A 3-year-old boy with a congenital heart defect is brought to the
clinic by his mother because he has a fever and an earache.
During the assessment, the mother asks the nurse why her child
,is at the 5th percentile for weight and height for his age. Which
response is best for the nurse to provide?
A. "Does your child seem mentally slower than his peers also?"
B. "Haven't you been feeding him according to recommended
daily allowances for children?"
C. "His smaller size is probably due to the heart disease"
D. "You should not worry about the growth tables. They are
only averages for children." Correct Answers C. "His smaller
size is probably due to the heart disease"
A 41-week gestation primigravida woman is admitted to labor
and delivery for induction of labor. Which finding should the
nurse report to the healthcare provider before initiating the
infusion of oxytocin?
A. Regular contractions occurring every 10 minutes
B. Sterile vaginal exam revealing 3cm dilation
C. Biophysical profile results showing oligohydramnios
D. Fetal heart tones located in upper right quadrants Correct
Answers D. Fetal heart tones located in upper right quadrants
A 62-year-old male client tells the nurse that he has a high-
density lipoprotein (HDL) level of 85 mg/dl. Which action
should the nurse take?
A. Encourage the client to reduce consumption of fatty foods
B. Ask the client about hereditary cardiac risk factors
C. Confirm that this value is helpful in reducing cardiac risk
D. Explain that the client may need medication therapy Correct
Answers C. Confirm that this value is helping in reducing
cardiac risk
,A child newly diagnosed with sickle cell anemia (SCA) is being
discharged from the hospital. Which information is most
important for the nurse to provide the parents prior to discharge?
A. Signs of addiction to opioid pain medication
B. Information about non-pharmaceutical pain relief measures
C. Referral for social services for the child and family
D. Instructions about how much fluid the child should drink
Correct Answers D. Instructions about how much fluid the child
should drink
A client arrives for an annual physical exam and complains of
having calf pain. The client's health history reveals peripheral
arterial disease. Which question should the nurse ask the client
about expected findings related to chronic arterial symptoms?
A. Were your legs ever suddenly swollen, red, warm, and
painful?
B. Does the calf pain occur when walking short distances?
C. Did you receive treatment for weeping ulcers on lower legs?
D. Have you experienced ankle edema and varicose veins?
Correct Answers B. Does the calf pain occur when walking
short distances?
A client develops urticaria on the trunk and neck shortly after a
secondary infusion of piperacillin is initiated. In what order
should the nurse implement these interventions? Correct
Answers 1. Stop the infusion
2. Assess vital signs
3. Contact the healthcare provider
4. Document reaction to the drug
5. Initiate an adverse event report
, A client has both a primary IV infusion and a secondary infusion
of medication. An infusion pump is not available. The nurse
needs to change the rate of flow of the secondary infusion.
Where should the nurse regulate the rate of the secondary IV?
Correct Answers
A client is admitted with acute pancreatitis. The client admits to
drinking a pint of bourbon daily. The nurse medicates the client
for pain and monitors vital signs every 2 hours. Which finding
should the nurse report immediately to the healthcare provider?
A. Anorexia and abdominal distention
B. Abdominal pain and vomiting
C. Confusion and tremors
D. Yellowing and itching of skin Correct Answers C.
Confusion and tremors
A client is admitted with an exacerbation of heart failure
secondary to COPD. Which observations by the nurse require
immediate intervention to reduce the likelihood of harm to this
client?
A. A bedside commode is positioned near the bed
B. A saline lock is present in the right forearm
C. A full pitcher of water is on the bedside table
D. A low sodium diet tray was brought to the room
E. The client is lying in a supine position in bed Correct
Answers C. A full pitcher of water is on the bedside table
E. The client is lying in a supine position in bed
A client is admitted with the diagnosis of Wernicke's syndrome.
Which assessment finding should the nurse use in planning the
client's care?
COMPLETE SOLUTIONS
A 12-year-old client who had an appendectomy two days ago is
receiving 0.9% normal saline at 50mL/hr. The client's urine
specific gravity is 1.035. Which action should the nurse
implement?
A. Assess bowel sounds in all quadrants
B. Encourage popsicles and fluids of choice
C. Evaluate postural blood pressure measurements
D. Obtain a specimen for urinalysis Correct Answers B.
Encourage popsicles and fluids of choice
A 3-year-old boy was successfully toilet trained prior to his
admission to the hospital for injuries sustained from a fall. His
parents are very concerned that the child has regressed in his
toileting behaviors. Which information should the nurse provide
to the parents?
A. Diapering will be provided since hospitalization is stressful to
preschoolers
B. Children usually resume their toileting behaviors when they
leave the hospital
C. A potty chair should be brought from home so he can
maintain his toileting skills
D. A retraining program will need to be initiated when the child
returns home Correct Answers B. Children usually resume
their toileting behaviors when they leave the hospital
A 3-year-old boy with a congenital heart defect is brought to the
clinic by his mother because he has a fever and an earache.
During the assessment, the mother asks the nurse why her child
,is at the 5th percentile for weight and height for his age. Which
response is best for the nurse to provide?
A. "Does your child seem mentally slower than his peers also?"
B. "Haven't you been feeding him according to recommended
daily allowances for children?"
C. "His smaller size is probably due to the heart disease"
D. "You should not worry about the growth tables. They are
only averages for children." Correct Answers C. "His smaller
size is probably due to the heart disease"
A 41-week gestation primigravida woman is admitted to labor
and delivery for induction of labor. Which finding should the
nurse report to the healthcare provider before initiating the
infusion of oxytocin?
A. Regular contractions occurring every 10 minutes
B. Sterile vaginal exam revealing 3cm dilation
C. Biophysical profile results showing oligohydramnios
D. Fetal heart tones located in upper right quadrants Correct
Answers D. Fetal heart tones located in upper right quadrants
A 62-year-old male client tells the nurse that he has a high-
density lipoprotein (HDL) level of 85 mg/dl. Which action
should the nurse take?
A. Encourage the client to reduce consumption of fatty foods
B. Ask the client about hereditary cardiac risk factors
C. Confirm that this value is helpful in reducing cardiac risk
D. Explain that the client may need medication therapy Correct
Answers C. Confirm that this value is helping in reducing
cardiac risk
,A child newly diagnosed with sickle cell anemia (SCA) is being
discharged from the hospital. Which information is most
important for the nurse to provide the parents prior to discharge?
A. Signs of addiction to opioid pain medication
B. Information about non-pharmaceutical pain relief measures
C. Referral for social services for the child and family
D. Instructions about how much fluid the child should drink
Correct Answers D. Instructions about how much fluid the child
should drink
A client arrives for an annual physical exam and complains of
having calf pain. The client's health history reveals peripheral
arterial disease. Which question should the nurse ask the client
about expected findings related to chronic arterial symptoms?
A. Were your legs ever suddenly swollen, red, warm, and
painful?
B. Does the calf pain occur when walking short distances?
C. Did you receive treatment for weeping ulcers on lower legs?
D. Have you experienced ankle edema and varicose veins?
Correct Answers B. Does the calf pain occur when walking
short distances?
A client develops urticaria on the trunk and neck shortly after a
secondary infusion of piperacillin is initiated. In what order
should the nurse implement these interventions? Correct
Answers 1. Stop the infusion
2. Assess vital signs
3. Contact the healthcare provider
4. Document reaction to the drug
5. Initiate an adverse event report
, A client has both a primary IV infusion and a secondary infusion
of medication. An infusion pump is not available. The nurse
needs to change the rate of flow of the secondary infusion.
Where should the nurse regulate the rate of the secondary IV?
Correct Answers
A client is admitted with acute pancreatitis. The client admits to
drinking a pint of bourbon daily. The nurse medicates the client
for pain and monitors vital signs every 2 hours. Which finding
should the nurse report immediately to the healthcare provider?
A. Anorexia and abdominal distention
B. Abdominal pain and vomiting
C. Confusion and tremors
D. Yellowing and itching of skin Correct Answers C.
Confusion and tremors
A client is admitted with an exacerbation of heart failure
secondary to COPD. Which observations by the nurse require
immediate intervention to reduce the likelihood of harm to this
client?
A. A bedside commode is positioned near the bed
B. A saline lock is present in the right forearm
C. A full pitcher of water is on the bedside table
D. A low sodium diet tray was brought to the room
E. The client is lying in a supine position in bed Correct
Answers C. A full pitcher of water is on the bedside table
E. The client is lying in a supine position in bed
A client is admitted with the diagnosis of Wernicke's syndrome.
Which assessment finding should the nurse use in planning the
client's care?
