**HESI RN Exit Exam Version 8: Ultimate 125-Question Comprehensive Final Review**
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Question 1
A nurse is assessing a client who is 2 hours post-cesarean delivery. The client's fundus is boggy, deviated
to the right, and located 3 cm above the umbilicus. Which of the following actions should the nurse take
first?
A. Administer oxytocin as prescribed
B. Perform fundal massage
C. Assist the client to void
D. Notify the healthcare provider
💫ANSWER✔️✔️: C. Assist the client to void
💫RATIONALE✔️✔️: A distended bladder displaces the uterus upward and to the right, preventing
contraction; voiding often corrects the boggy fundus.
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Question 2
A nurse is providing discharge teaching to a client with a new prescription for phenelzine (MAOI). Which
of the following foods should the nurse instruct the client to avoid?
A. Broiled chicken
B. Aged cheddar cheese
C. Apple juice
D. White rice
💫ANSWER✔️✔️: B. Aged cheddar cheese
💫RATIONALE✔️✔️: Aged cheese contains tyramine, which can cause hypertensive crisis when combined
with MAOIs.
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Question 3
A nurse is caring for a client who is receiving a continuous IV heparin infusion for a DVT. The client's
aPTT is 120 seconds, and the control is 30 seconds. Which of the following medications should the nurse
anticipate administering?
A. Protamine sulfate
,B. Vitamin K
C. Fresh frozen plasma
D. Aminocaproic acid
💫ANSWER✔️✔️: A. Protamine sulfate
💫RATIONALE✔️✔️: aPTT 4 times control indicates severe over-anticoagulation; protamine sulfate
reverses heparin.
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Question 4
A nurse is assessing a client who has a new diagnosis of bacterial meningitis. Which of the following
findings should the nurse expect?
A. Kernig's sign and Brudzinski's sign
B. Flaccid paralysis and areflexia
C. Bilateral ptosis and diplopia
D. Hyperreflexia and clonus
💫ANSWER✔️✔️: A. Kernig's sign and Brudzinski's sign
💫RATIONALE✔️✔️: Kernig's (resistance to knee extension) and Brudzinski's (neck flexion causes hip
flexion) are classic meningeal signs.
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Question 5
A nurse is caring for a client with a new ileostomy following a total colectomy. The nurse notes that the
stoma is edematous, dark red, and moist. Which of the following actions should the nurse take?
A. Apply ice to the stoma to reduce swelling
B. Notify the healthcare provider immediately
C. Document the finding as normal for a new stoma
D. Gently massage the stoma to restore color
💫ANSWER✔️✔️: C. Document the finding as normal for a new stoma
💫RATIONALE✔️✔️: A new stoma is expected to be edematous and dark red/moist (like the inside of the
mouth) for 4-6 weeks post-op.
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Question 6
,A nurse is providing discharge teaching to a client with a new diagnosis of heart failure. Which of the
following statements by the client indicates understanding?
A. "I will weigh myself weekly and report any gain of 2 pounds."
B. "I will notify my provider if I have a cough that gets worse."
C. "I can stop my diuretic if I feel short of breath."
D. "I should limit my fluid intake to 3 liters per day."
💫ANSWER✔️✔️: B. "I will notify my provider if I have a cough that gets worse."
💫RATIONALE✔️✔️: A worsening cough may indicate pulmonary congestion or ACE inhibitor side effect;
requires evaluation.
---
Question 7
A nurse is caring for a client who has a new diagnosis of acute pancreatitis. Which of the following
laboratory findings should the nurse expect?
A. Elevated serum lipase
B. Decreased serum glucose
C. Elevated serum calcium
D. Decreased white blood cell count
💫ANSWER✔️✔️: A. Elevated serum lipase
💫RATIONALE✔️✔️: Serum lipase is the most specific and sensitive marker for acute pancreatitis,
remaining elevated for 7-14 days.
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Question 8
A nurse is assessing a client who is receiving a blood transfusion. The client reports low back pain and
chills. Which of the following actions should the nurse take first?
A. Stop the transfusion
B. Slow the infusion rate
C. Administer acetaminophen
D. Notify the healthcare provider
💫ANSWER✔️✔️: A. Stop the transfusion
, 💫RATIONALE✔️✔️: Low back pain and chills indicate an acute hemolytic reaction; stopping the
transfusion is the priority.
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Question 9
A nurse is providing teaching to a client with a new prescription for metformin. Which of the following
statements by the client indicates understanding?
A. "I will take this medication on an empty stomach."
B. "I should avoid drinking alcohol while taking this medication."
C. "Expect my urine to turn orange while taking this medication."
D. "I will report any weight gain to my provider."
💫ANSWER✔️✔️: B. "I should avoid drinking alcohol while taking this medication."
💫RATIONALE✔️✔️: Alcohol increases the risk of lactic acidosis with metformin; clients should avoid or
limit alcohol.
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Question 10
A nurse is caring for a client who has a chest tube connected to a closed drainage system following a
thoracotomy. The nurse notes continuous bubbling in the water seal chamber. Which of the following
actions should the nurse take?
A. Increase the suction pressure
B. Clamp the chest tube immediately
C. Check the system for an air leak
D. Document this as an expected finding
💫ANSWER✔️✔️: C. Check the system for an air leak
💫RATIONALE✔️✔️: Continuous bubbling in the water seal chamber indicates an air leak; the nurse
should assess connections and the insertion site.
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Question 11
A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which of the following
findings is a late sign of hypoxemia?
A. Clubbing of the fingers
B. Cyanosis of the lips and nail beds
---
Question 1
A nurse is assessing a client who is 2 hours post-cesarean delivery. The client's fundus is boggy, deviated
to the right, and located 3 cm above the umbilicus. Which of the following actions should the nurse take
first?
A. Administer oxytocin as prescribed
B. Perform fundal massage
C. Assist the client to void
D. Notify the healthcare provider
💫ANSWER✔️✔️: C. Assist the client to void
💫RATIONALE✔️✔️: A distended bladder displaces the uterus upward and to the right, preventing
contraction; voiding often corrects the boggy fundus.
---
Question 2
A nurse is providing discharge teaching to a client with a new prescription for phenelzine (MAOI). Which
of the following foods should the nurse instruct the client to avoid?
A. Broiled chicken
B. Aged cheddar cheese
C. Apple juice
D. White rice
💫ANSWER✔️✔️: B. Aged cheddar cheese
💫RATIONALE✔️✔️: Aged cheese contains tyramine, which can cause hypertensive crisis when combined
with MAOIs.
---
Question 3
A nurse is caring for a client who is receiving a continuous IV heparin infusion for a DVT. The client's
aPTT is 120 seconds, and the control is 30 seconds. Which of the following medications should the nurse
anticipate administering?
A. Protamine sulfate
,B. Vitamin K
C. Fresh frozen plasma
D. Aminocaproic acid
💫ANSWER✔️✔️: A. Protamine sulfate
💫RATIONALE✔️✔️: aPTT 4 times control indicates severe over-anticoagulation; protamine sulfate
reverses heparin.
---
Question 4
A nurse is assessing a client who has a new diagnosis of bacterial meningitis. Which of the following
findings should the nurse expect?
A. Kernig's sign and Brudzinski's sign
B. Flaccid paralysis and areflexia
C. Bilateral ptosis and diplopia
D. Hyperreflexia and clonus
💫ANSWER✔️✔️: A. Kernig's sign and Brudzinski's sign
💫RATIONALE✔️✔️: Kernig's (resistance to knee extension) and Brudzinski's (neck flexion causes hip
flexion) are classic meningeal signs.
---
Question 5
A nurse is caring for a client with a new ileostomy following a total colectomy. The nurse notes that the
stoma is edematous, dark red, and moist. Which of the following actions should the nurse take?
A. Apply ice to the stoma to reduce swelling
B. Notify the healthcare provider immediately
C. Document the finding as normal for a new stoma
D. Gently massage the stoma to restore color
💫ANSWER✔️✔️: C. Document the finding as normal for a new stoma
💫RATIONALE✔️✔️: A new stoma is expected to be edematous and dark red/moist (like the inside of the
mouth) for 4-6 weeks post-op.
---
Question 6
,A nurse is providing discharge teaching to a client with a new diagnosis of heart failure. Which of the
following statements by the client indicates understanding?
A. "I will weigh myself weekly and report any gain of 2 pounds."
B. "I will notify my provider if I have a cough that gets worse."
C. "I can stop my diuretic if I feel short of breath."
D. "I should limit my fluid intake to 3 liters per day."
💫ANSWER✔️✔️: B. "I will notify my provider if I have a cough that gets worse."
💫RATIONALE✔️✔️: A worsening cough may indicate pulmonary congestion or ACE inhibitor side effect;
requires evaluation.
---
Question 7
A nurse is caring for a client who has a new diagnosis of acute pancreatitis. Which of the following
laboratory findings should the nurse expect?
A. Elevated serum lipase
B. Decreased serum glucose
C. Elevated serum calcium
D. Decreased white blood cell count
💫ANSWER✔️✔️: A. Elevated serum lipase
💫RATIONALE✔️✔️: Serum lipase is the most specific and sensitive marker for acute pancreatitis,
remaining elevated for 7-14 days.
---
Question 8
A nurse is assessing a client who is receiving a blood transfusion. The client reports low back pain and
chills. Which of the following actions should the nurse take first?
A. Stop the transfusion
B. Slow the infusion rate
C. Administer acetaminophen
D. Notify the healthcare provider
💫ANSWER✔️✔️: A. Stop the transfusion
, 💫RATIONALE✔️✔️: Low back pain and chills indicate an acute hemolytic reaction; stopping the
transfusion is the priority.
---
Question 9
A nurse is providing teaching to a client with a new prescription for metformin. Which of the following
statements by the client indicates understanding?
A. "I will take this medication on an empty stomach."
B. "I should avoid drinking alcohol while taking this medication."
C. "Expect my urine to turn orange while taking this medication."
D. "I will report any weight gain to my provider."
💫ANSWER✔️✔️: B. "I should avoid drinking alcohol while taking this medication."
💫RATIONALE✔️✔️: Alcohol increases the risk of lactic acidosis with metformin; clients should avoid or
limit alcohol.
---
Question 10
A nurse is caring for a client who has a chest tube connected to a closed drainage system following a
thoracotomy. The nurse notes continuous bubbling in the water seal chamber. Which of the following
actions should the nurse take?
A. Increase the suction pressure
B. Clamp the chest tube immediately
C. Check the system for an air leak
D. Document this as an expected finding
💫ANSWER✔️✔️: C. Check the system for an air leak
💫RATIONALE✔️✔️: Continuous bubbling in the water seal chamber indicates an air leak; the nurse
should assess connections and the insertion site.
---
Question 11
A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which of the following
findings is a late sign of hypoxemia?
A. Clubbing of the fingers
B. Cyanosis of the lips and nail beds
