HESI RN EXIT EXAM LEGACY V2 - Questions &Answers
/.The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus
and learns that the client has a current blood glucose level of 720 mg/dL. When
assessing the client, what is the priority?
A. Assess for signs of fluid volume deficit
B. Observe wound drainage characteristics
C. Measure the level of acute pain
D. Determine when the client last ate - Answer-✅A. Assess for signs of fluid volume
deficit
/.A male client tells the nurse that he is concerned that he may have a stomach ulcer,
because he is experiencing heartburn and dull gnawing pain that is relieved when he
eats. Which is the best response by the nurse?
A. Encourage the client to obtain a complete physical exam, since these symptoms are
consistent with an ulcer
B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not
relieved with food
C. Instruct the client that these mild symptoms can generally be controlled with changes
in his diet
D. Advise the client that he needs to seek immediate medical evaluation and treatment
of these symptoms - Answer-✅A. Encourage the client to obtain a complete physical
exam, since these symptoms are consistent with an ulcer
/.A male client with stomach cancer returns to the unit following a total gastrectomy. He
has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hr
IV. One hour after admission to the unit, the nurse notes 300mL of blood in the suction
canister, the client's heart rate is 155 beats/minute, and his blood pressure is 78/48
mmHg. In addition to reporting the findings to the surgeon, which action should the
nurse implement first?
A. Measure and document the client's urinary output
B. Request the client's reserved unit of packed red blood cells
C. Prepare for placement of a central venous catheter
D. Increase the infusion rate of Lactated Ringer's solution - Answer-✅D. Increase the
infusion rate of Lactated Ringer's solution
/.A heparin infusion is prescribed for a client who weighs 220 pounds. After
administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the
heparin solution as 18 units/kg/hour. The available solution is Heparin Sodium 25,000
Units in 5% Dextrose Injection 250 mL. The nurse should program the infusion pump to
deliver how many mL/hour? - Answer-✅-1st: calculate the weight = 220/2.2= 100kg
-Then calculate total dose in units = 18units x 100kg = 1800 units/hr
,- 25000 units - in 250
1800 units ---in X ml
x = 1800 x 250/25000 =18 mL/hr
/.An adult male who fell 20 feet from the roof of his home has multiple injuries, including
a right pneumothorax. Chest tubes were inserted in the emergency department prior to
his transfer to the intensive care unit (ICU). The nurse notes that the suction control
chamber is bubbling at the -10cm H2O mark, which fluctuation in the water seal, and
over the past hour 75 mL of bright red blood is measured in the collection chamber.
Which intervention should the nurse implement?
A. Add sterile water to the suction control chamber
B. Give blood from the collection chamber as autotransfusion
C. Manipulate blood in tubing to drain into chamber
D. Increase wall suction to eliminate fluctuation in water seal - Answer-✅A. Add sterile
water to the suction control chamber
/.An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife
approaches the nurse and asks how she will know that her husband's death is imminent
because their two adult children want to be there when he dies. Which is the best
response by the nurse?
A. Gather information regarding how long it will take for the children to arrive
B. Explain that the client will start to lose consciousness and the body systems will slow
down
C. Reassure the spouse that the healthcare provider will notify when to call the children
D. Offer to discuss the client's health status with each of the adult children - Answer-
✅B. Explain that the client will start to lose consciousness and the body systems will
slow down
/.The charge nurse of a critical care unit is informed at the beginning of the shift that
less than the optimal number of registered nurses will be working that shift. In planning
assignments, which client should receive the most care hours by a registered nurse
(RN)?
A. A 48-year-old marathon runner with a central venous catheter who is experiencing
nausea and vomiting due to electrolyte disturbance following a race
B. A 34-year-old admitted today after an emergency appendectomy who has a
peripheral intravenous catheter and a Foley catheter
C. A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen
via nasal cannula and has a saline-locked peripheral intravenous catheter
D. An 82-year-old client with Alzheimer's disease and a newly-fractured femur who has
a Foley catheter and soft wrist restraints applied - Answer-✅D. An 82-year-old client
with Alzheimer's disease and a newly-fractured femur who has a Foley catheter and soft
wrist restraints applied
/.The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled
"750 mcg/2.4mL". How many mL should the nurse administer? Round to nearest tenth.
- Answer-✅0.2 mL
,/.In caring for a client with Cushing's Syndrome, which serum laboratory value is most
important for the nurse to monitor?
A. Creatinine
B. Lactate
C. Glucose
D. Hemoglobin - Answer-✅C. Glucose
/.A client who received hemodialysis yesterday is experiencing a blood pressure of
200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute.
The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen
saturation on room air of 89%. Which action should the nurse take first?
A. Elevate the foot of the bed
B. Restrict the client's fluids
C. Begin supplemental oxygen
D. Prepare client for hemodialysis - Answer-✅C. Begin supplemental oxygen
/.When caring for a client with full thickness burns to both lower extremities, which
assessment findings warrant immediate intervention? Select all that apply
A. Sloughing tissue around wound edges
B. Complaint of increased pain and pressure
C. Change in the quality of the peripheral pulses
D. Loss of sensation to the left lower extremity
E. Weeping serosanguineous fluid from wounds - Answer-✅B. Complaint of increased
pain and pressure
C. Change in the quality of the peripheral pulses
D. Loss of sensation to the left lower extremity
/.An older client is admitted with fluid volume deficit and dehydration. Which assessment
finding is the best indicator of hydration that the nurse should report to the healthcare
provider?
A. Urine specific gravity is 1.040
B. Systolic blood pressure decreases 10 points when standing
C. The client denies being thirsty
D. Skin tenting occurs when the client's forearm is pinched - Answer-✅D. Skin tenting
occurs when the client's forearm is pinched
/.The healthcare provider prescribes methylergonovine maleate for a postpartum client
with uterine atony. What finding should indicate to the nurse to withhold the next dose of
the medication?
A. Difficulty locating the uterine fundus
B. Excessive lochia
C. Saturation of more than one pad per hour
D. Hypertension - Answer-✅D. Hypertension
, /.After an inservice about electronic health record (EHR) security and safeguarding
client information, the nurse observes a colleague going home with printed copies of
client information in a uniform pocket. Which action should the nurse take?
A. File a detailed incident report with the specific hiring facility
B. Warn the colleague that their actions are unprofessional
C. Comment anonymously about the action on a staff discussion board
D. Communicate the colleague's actions to the unit charge nurse - Answer-✅A. File a
detailed incident report with the specific hiring facility
/.The nurse is evaluating a tertiary prevention program for clients with cardiovascular
disease implemented in a rural health clinic. Which outcome indicates the program is
effective?
A. At-risk clients received an increased number of routine health screenings
B. Clients reported having new confidence in making healthy food choices
C. Clients who incurred disease complications promptly received rehabilitation
D. Client relapse of 30% in a 5-year community-wide anti-smoking campaign - Answer-
✅C. Clients who incurred disease complications promptly received rehabilitation
/.While caring for a client's postoperative dressing, the nurse observes purulent
drainage at the wound. Before reporting this finding to the healthcare provider, the
nurse should review which of the client's laboratory values?
A. Culture for sensitive organisms
B. Serum blood glucose (BG) level
C. Creatinine level
D. Serum albumin - Answer-✅A. Culture for sensitive organisms
/.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 - Answer-✅C. Confusion and tremors
/.A client with leukemia who is receiving a myleosuppressive chemotherapy has a
platelet count of 25,000/mm3. Which intervention is most important for the nurse to
include in this client's plan of care?
A. Assess urine and stool for occult blood
B. Monitor for signs of activity intolerance
C. Require visitors to wear respiratory masks
D. Obtain client's temperature q4 hours - Answer-✅A. Assess urine and stool for occult
blood
/.When assessing a 6-month-old infant, the nurse determines that the anterior fontanel
is bulging. In which situation would this findings be most significant?
A. Crying
/.The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus
and learns that the client has a current blood glucose level of 720 mg/dL. When
assessing the client, what is the priority?
A. Assess for signs of fluid volume deficit
B. Observe wound drainage characteristics
C. Measure the level of acute pain
D. Determine when the client last ate - Answer-✅A. Assess for signs of fluid volume
deficit
/.A male client tells the nurse that he is concerned that he may have a stomach ulcer,
because he is experiencing heartburn and dull gnawing pain that is relieved when he
eats. Which is the best response by the nurse?
A. Encourage the client to obtain a complete physical exam, since these symptoms are
consistent with an ulcer
B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not
relieved with food
C. Instruct the client that these mild symptoms can generally be controlled with changes
in his diet
D. Advise the client that he needs to seek immediate medical evaluation and treatment
of these symptoms - Answer-✅A. Encourage the client to obtain a complete physical
exam, since these symptoms are consistent with an ulcer
/.A male client with stomach cancer returns to the unit following a total gastrectomy. He
has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hr
IV. One hour after admission to the unit, the nurse notes 300mL of blood in the suction
canister, the client's heart rate is 155 beats/minute, and his blood pressure is 78/48
mmHg. In addition to reporting the findings to the surgeon, which action should the
nurse implement first?
A. Measure and document the client's urinary output
B. Request the client's reserved unit of packed red blood cells
C. Prepare for placement of a central venous catheter
D. Increase the infusion rate of Lactated Ringer's solution - Answer-✅D. Increase the
infusion rate of Lactated Ringer's solution
/.A heparin infusion is prescribed for a client who weighs 220 pounds. After
administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the
heparin solution as 18 units/kg/hour. The available solution is Heparin Sodium 25,000
Units in 5% Dextrose Injection 250 mL. The nurse should program the infusion pump to
deliver how many mL/hour? - Answer-✅-1st: calculate the weight = 220/2.2= 100kg
-Then calculate total dose in units = 18units x 100kg = 1800 units/hr
,- 25000 units - in 250
1800 units ---in X ml
x = 1800 x 250/25000 =18 mL/hr
/.An adult male who fell 20 feet from the roof of his home has multiple injuries, including
a right pneumothorax. Chest tubes were inserted in the emergency department prior to
his transfer to the intensive care unit (ICU). The nurse notes that the suction control
chamber is bubbling at the -10cm H2O mark, which fluctuation in the water seal, and
over the past hour 75 mL of bright red blood is measured in the collection chamber.
Which intervention should the nurse implement?
A. Add sterile water to the suction control chamber
B. Give blood from the collection chamber as autotransfusion
C. Manipulate blood in tubing to drain into chamber
D. Increase wall suction to eliminate fluctuation in water seal - Answer-✅A. Add sterile
water to the suction control chamber
/.An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife
approaches the nurse and asks how she will know that her husband's death is imminent
because their two adult children want to be there when he dies. Which is the best
response by the nurse?
A. Gather information regarding how long it will take for the children to arrive
B. Explain that the client will start to lose consciousness and the body systems will slow
down
C. Reassure the spouse that the healthcare provider will notify when to call the children
D. Offer to discuss the client's health status with each of the adult children - Answer-
✅B. Explain that the client will start to lose consciousness and the body systems will
slow down
/.The charge nurse of a critical care unit is informed at the beginning of the shift that
less than the optimal number of registered nurses will be working that shift. In planning
assignments, which client should receive the most care hours by a registered nurse
(RN)?
A. A 48-year-old marathon runner with a central venous catheter who is experiencing
nausea and vomiting due to electrolyte disturbance following a race
B. A 34-year-old admitted today after an emergency appendectomy who has a
peripheral intravenous catheter and a Foley catheter
C. A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen
via nasal cannula and has a saline-locked peripheral intravenous catheter
D. An 82-year-old client with Alzheimer's disease and a newly-fractured femur who has
a Foley catheter and soft wrist restraints applied - Answer-✅D. An 82-year-old client
with Alzheimer's disease and a newly-fractured femur who has a Foley catheter and soft
wrist restraints applied
/.The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled
"750 mcg/2.4mL". How many mL should the nurse administer? Round to nearest tenth.
- Answer-✅0.2 mL
,/.In caring for a client with Cushing's Syndrome, which serum laboratory value is most
important for the nurse to monitor?
A. Creatinine
B. Lactate
C. Glucose
D. Hemoglobin - Answer-✅C. Glucose
/.A client who received hemodialysis yesterday is experiencing a blood pressure of
200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute.
The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen
saturation on room air of 89%. Which action should the nurse take first?
A. Elevate the foot of the bed
B. Restrict the client's fluids
C. Begin supplemental oxygen
D. Prepare client for hemodialysis - Answer-✅C. Begin supplemental oxygen
/.When caring for a client with full thickness burns to both lower extremities, which
assessment findings warrant immediate intervention? Select all that apply
A. Sloughing tissue around wound edges
B. Complaint of increased pain and pressure
C. Change in the quality of the peripheral pulses
D. Loss of sensation to the left lower extremity
E. Weeping serosanguineous fluid from wounds - Answer-✅B. Complaint of increased
pain and pressure
C. Change in the quality of the peripheral pulses
D. Loss of sensation to the left lower extremity
/.An older client is admitted with fluid volume deficit and dehydration. Which assessment
finding is the best indicator of hydration that the nurse should report to the healthcare
provider?
A. Urine specific gravity is 1.040
B. Systolic blood pressure decreases 10 points when standing
C. The client denies being thirsty
D. Skin tenting occurs when the client's forearm is pinched - Answer-✅D. Skin tenting
occurs when the client's forearm is pinched
/.The healthcare provider prescribes methylergonovine maleate for a postpartum client
with uterine atony. What finding should indicate to the nurse to withhold the next dose of
the medication?
A. Difficulty locating the uterine fundus
B. Excessive lochia
C. Saturation of more than one pad per hour
D. Hypertension - Answer-✅D. Hypertension
, /.After an inservice about electronic health record (EHR) security and safeguarding
client information, the nurse observes a colleague going home with printed copies of
client information in a uniform pocket. Which action should the nurse take?
A. File a detailed incident report with the specific hiring facility
B. Warn the colleague that their actions are unprofessional
C. Comment anonymously about the action on a staff discussion board
D. Communicate the colleague's actions to the unit charge nurse - Answer-✅A. File a
detailed incident report with the specific hiring facility
/.The nurse is evaluating a tertiary prevention program for clients with cardiovascular
disease implemented in a rural health clinic. Which outcome indicates the program is
effective?
A. At-risk clients received an increased number of routine health screenings
B. Clients reported having new confidence in making healthy food choices
C. Clients who incurred disease complications promptly received rehabilitation
D. Client relapse of 30% in a 5-year community-wide anti-smoking campaign - Answer-
✅C. Clients who incurred disease complications promptly received rehabilitation
/.While caring for a client's postoperative dressing, the nurse observes purulent
drainage at the wound. Before reporting this finding to the healthcare provider, the
nurse should review which of the client's laboratory values?
A. Culture for sensitive organisms
B. Serum blood glucose (BG) level
C. Creatinine level
D. Serum albumin - Answer-✅A. Culture for sensitive organisms
/.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 - Answer-✅C. Confusion and tremors
/.A client with leukemia who is receiving a myleosuppressive chemotherapy has a
platelet count of 25,000/mm3. Which intervention is most important for the nurse to
include in this client's plan of care?
A. Assess urine and stool for occult blood
B. Monitor for signs of activity intolerance
C. Require visitors to wear respiratory masks
D. Obtain client's temperature q4 hours - Answer-✅A. Assess urine and stool for occult
blood
/.When assessing a 6-month-old infant, the nurse determines that the anterior fontanel
is bulging. In which situation would this findings be most significant?
A. Crying
